Attachment A SOW - 12 pages.pdf

Scope of Work

Project Number: 437-23-104

Project Title: Update Wing 4B

Description of Work: Construction work shall include, but shall not be limited to providing all labor, materials, equipment, etc. necessary to complete Fargo Veterans Affairs (VA) Health Care System construction project 437-23-104, Update Wing 4B in accordance with the Scope of Work (SOW), the contract documents, National Fire Protection Agency (NFPA), local building codes, VA and American Society of Healthcare Engineering (ASHE) facility standards, and other applicable requirements.

The project shall include, but shall not be limited to: construction of hard wall construction barriers, demolition of floors and ceiling, flooring, access panels, furniture and wall finishes per applicable fire codes and to satisfy fire ratings. All objects will be pick proof caulked into place. Phasing is critical to construction. Work Duties to include HVAC, lighting, plumbing, fire suppression and protection, to provide an overall "face-lift" renovation to the locked mental health ward.

Construction barrier will be hard walled. Infection Control Risk Assessment (ICRA) is class IV unless otherwise noted.

All work is within the locked ward. Those doing the work are Solely responsible for their tools and materials, and must be checked with a list at every entrance and exit of the locked ward. A sign-in sheet will be provided to verify they have accounted for All tools and materials, coming on and off the unit.

Anyone entering into the space shall participate in a one time, hour long training. Contractors will be expected to participate in All requirements outlined in the Fargo Locked ward procedures. Work that generates noise and vibration can agitate patients and contractors should make every effort to minimize impacts to patients. For patient safety, work may be paused until patients can be calmed down by VA staff.

Contractor shall ensure downtimes are kept to a minimum and are as scheduled with the VA Contracting Officer Representative (COR). Contractor may be expected to accomplish work that disrupts utilities or causes excessive dust, vibration or noise between 4pm and 8pm.

Period of Performance will be 450 days from receipt the Notice to Proceed (NTP). This includes time for all contractors to be background checked and badged. The GC will be required to submit completed forms OF306, Self certification of continuous services and Contractor background investigation request for every individual to be badged. Badged individuals will submit to finger printing (approximately 1hr) and to fill out an eQIP (approximately 4 hours). Every individual on the project shall review the following 4 pages, sign and provide to the COR prior to being allowed on site. See Attachment A for Schedule.

Estimated Cost Range Magnitude for this project is between $1,000,000.00 and $2,000,000.00.

This contract does have a requirement for sole superintendent. The Safety supervisor is allowed to be the competent person overseeing work. All contractors must provide proof they have read and understand the Orientation to locked inpatient mental health unit (4B) or be considered ineligible for work on this project.

Schedule Project Number: 437-23-104 Project Title: Update Wing 4B

Below represents an approximate schedule for the Period of Performance.

Duration of Work: 120 days for badging/background check, 450 days for construction

Item Day Contract Award D Pre-construction Conference D+15 Notice to Proceed

• Badging/Background Check Start

• Submittals Due

• Long-Lead Items

• Badging/Background Check Completion

D+20 D+35 D+50 D+80

D+155 Construction Start D+155 Construction Completion D+605

Page 2 of 4 Page 2 of 12

VA Privacy Training for Personnel without Access to VA Computer Systems or Direct Access to or the Use of VA Sensitive Information

The Department of Veterans Affairs, VA must comply with all applicable privacy and confidentiality statutes and regulations. One of the requirements in VA is to have all personnel trained annually on privacy requirements. “Privacy” represents what must be protected by VA in the collection, use, and disclosure of personal information whether the medium is electronic, paper or verbal.

This document satisfies the “basic” privacy training requirement for a contractor, volunteer, or other personnel only if the individual does not use VA sensitive information or protected health information (PHI) in any form such as electronic or paper or have access to any VA computer system such as VA Time and Attendance System (VATAS), Computerized Patient Record System (CPRS), Joint Legacy Viewer (JLV), Veterans Health Information Exchange (VHIE), Compensation and Pension Record Interchange (CAPRI).

You will find this training outlines your role and responsibility for protecting VA sensitive information (medical, financial, or educational) that you may incidentally or accidentally see or overhear.

If you have direct access to VA sensitive information or access to a VA computer system where there is protected health information such as VaTAS, CPRS, JLV, VHIE or CAPRI you must take Privacy and HIPAA Focused Training (TMS 10203).

VA Privacy and Information Security Awareness and Rules of Behavior (TMS 10176) is always required to use or gain access to a VA computer system or VA sensitive information, whether or not protected health information is included. Both trainings are located within the VA Talent Management System (TMS): https://www.tms.va.gov

What is VA Sensitive Information/Data?

All Department information and/or data on any storage media or in any form or format, which requires protection due to the risk of harm that could result from inadvertent or deliberate disclosure, alteration, or destruction of the information. The term includes not only information that identifies an individual but also other information whose improper use or disclosure could adversely affect the ability of an agency to accomplish its mission, proprietary information, and records about individuals requiring protection under applicable confidentiality provisions.

What is Protected Health Information?

The HIPAA Privacy Rule defines protected health information as Individually Identifiable Health Information transmitted or maintained in any form or medium by a covered entity, such as VHA.

What is an “Incidental” Disclosure?

An incidental disclosure is one where an individual’s information may be disclosed incidentally even though appropriate safeguards are in place. Due to the nature of VA communications and practices, as well as the various environments in which Veterans receive healthcare or other services from VA, the potential exists for a Veteran’s protected health information or VA sensitive information to be disclosed incidentally.

https://www.tms.va.gov/

For example:

• You overhear a healthcare provider’s conversation with another provider or patient even when the conversation is taking place appropriately.

• You may see limited Veteran information on sign-in sheets or white boards within a treating area of the facility.

• You may hear a Veteran’s name being called out for an appointment or when the Veteran is being transported/escorted to and from an appointment

Safeguards You Must Follow To Secure VA Sensitive Information:

• Secure any VA sensitive information found in unsecured public areas (parking lot, trash can, or vacated area) until information can be given to your supervisor or Privacy Officer. You must report such incidents to your Privacy Officer timely.

• Don’t take VA sensitive information off facilities grounds without VA permission unless the VA information is general public information, i.e., brochures/pamphlets.

• Don’t take pictures using a personal camera without the permission from the Medical Center Director.

• Any protected health information overheard or seen in VA should not be discussed or shared with anyone who does not have a need to know the information in the performance of their official job duties, this includes spouses, employers or colleagues.

• Do not share VA access cards, keys, or codes to enter the facility.

• Immediately report lost or stolen Personal Identity Verification (PIV) or Veteran Health Identification Cards (VHIC), VA keys or keypad lock codes to your supervisor or VA police.

• Do not use a VA computer using another VA employee’s access and password.

• Do not ask another VA employee to access your own protected health information. You must request this information in writing from the Release of Information section at your facility

What are the Six Privacy Laws and Statutes Governing VA?

1. Freedom of Information Act (FOIA) compels disclosure of reasonably described VA records or a reasonably segregated portion of the records to any person upon written request unless one or more of the nine exemptions apply.

2. Privacy Act of 1974 provides for the confidentiality of personal information about a living individual who is a United States citizen or an alien lawfully admitted to U.S. and whose information is retrieved by the individual’s name or other unique identifier, e.g. Social Security Number.

3. Health Insurance Portability and Accountability Act (HIPAA) provides for the improvement of the efficiency and effectiveness of health care systems by encouraging the development of health information systems through the establishment of standards and requirements for the electronic transmission, privacy, and security of certain health information.

4. 38 U.S.C. 5701 provides for the confidentiality of all VA patient and claimant information, with special protection for their names and home addresses.

5. 38 U.S.C. 7332 provides for the confidentiality of drug abuse, alcoholism and alcohol abuse, infection with the human immunodeficiency virus (HIV) and sickle cell anemia medical records and health information.

6. 38 U.S.C. 5705 provides for the confidentiality of designated medical-quality assurance documents.

What are the Privacy Rules Concerning Use and Disclosure?

You are not authorized to use or disclose protected health information. In general, VHA personnel may only use information for purposes of treatment, payment or healthcare operations when they have a need-to-know in the course of their official job duties. VHA may only disclose protected health information upon written request by the individual who is the subject of the information or as authorized by law.

How is Privacy Enforced?

There are both civil and criminal penalties, including monetary penalties that may be imposed if a privacy violation has taken place. Any willful negligent or intentional violation of an individual’s privacy by VA personnel, contract staff, volunteers, or others may result in such corrective action as deemed appropriate by VA including the potential loss of employment, contract, or volunteer status.

Know your VA/VHA Privacy Officer and Information Systems Security Officer. These are the individuals to whom you can report any potential violation of protected health information or VA sensitive information, or any other concerns regarding privacy of VA sensitive information.

YOU ARE RESPONSIBLE FOR PROTECTING THE CONFIDENTIAL INFORMATION

OF OUR VETERANS

Employee (Print Name) Date Employee Signature Print Name of Contract Agency, if contractor Zach Koutz_________________________________ Print Name of VHA Department/Supervisor/Contracting Officer

PROVIDE A COPY OF THIS FORM TO YOUR SUPERVISOR/CONTRACTING OFFICER

FOR DATA ENTRY INTO TALENT MANAGEMENT SYSTEM

Updated June 2018

Orientation to the Locked Inpatient Mental Health Unit (4B)

4B is a locked Inpatient Mental Health unit.

Only 4B staff or VA Police will have keys to enter/exit the unit.

All other staff, patients or visitors are screened for entry as appropriate.

Staff must wear appropriate identification for entry.

Entry to 4B is only possible through the double locked doors. On the right of the first locked door there is a phone to call to request entry onto the unit or otherwise communicate with staff.

The nurse’s station is located down from the locked doors and staff can electronically release the door to allow entry. Exit from the unit occurs similarly. Be aware that with unit entry or exit, staff must take special precaution to prevent patient elopement.

As a locked unit, all mental health patients are restricted to the unit. Patients may wear personal clothing per policy.

While most of the patients on the unit are hospitalized voluntarily, there may be patients hospitalized involuntarily on a mental illness “HOLD” or commitment and considered to be a danger to self or others. Any staff entering 4B must be acutely aware of the need for taking extra precaution to ensure the safety of patients and staff.

Every effort must be made to prevent patients from access to contraband or potentially harmful items.

Among the contraband prohibited from the unit are weapons, sharps, tools, glass, aluminum cans, illicit drugs, alcohol, and any form of rope or cord that could be used for hanging, plastic bags which could be used for suffocation, any form of tobacco, canes, crutches, or anything that could be used to injure self or others. When on the unit, all staff must be acutely aware and responsible for all items/materials brought with them onto the unit.

Panic alarm buttons are available at the nurse’s station for your safety. Buttons must be turned in before you leave.

Emergency response to 4B is unchanged from previous. All code responders will be allowed unit entry through the main entry across from the elevators.

Staff must take special precautions and maintain constant supervision of any supplies and potentially dangerous items brought onto the unit. Items should never be left out or accessible to patients. It is recommended that staff check in with 4B staff to see if there might be any special concerns on the unit for that day. (ex: patient concerns that might impact your duties). If you observe any patient safety concerns on the unit, notify the 4B staff immediately.

Contractor Background Investigation Request VA Organization Billing Information

Upload signed request to PSAC Resource Site.

Printed/Distilled Copy

Only original can be submitted to PSAC.

https://dvagov.sharepoint.com/sites/LIT/vasic/default.aspx

Form Approved:

OMB No. 3206-0182 Declaration for Federal Employment*

(*This form may also be used to assess fitness for federal contract employment)

Instructions The information collected on this form is used to determine your acceptability for Federal and Federal contract employment and your enrollment status in the Government's Life Insurance program. Most applicants are asked to complete this form after a tentative offer of employment has been made; however, depending on your position, you may be asked to complete this form earlier during the hiring process. Follow instructions that the agency provides. Before you are appointed you will be asked to update your responses on this form and on other materials submitted during the application process and then to recertify that your answers are true.

All your answers must be truthful and complete. A false statement on any part of this declaration or attached forms or sheets may be grounds for not hiring you, or for firing you after you begin work. Also, you may be punished by a fine or imprisonment (U.S. Code, title 18, section 1001).

Either type your responses on this form or print clearly in dark ink. If you need additional space, attach letter-size sheets (8.5" X 11").

Include your name, Social Security Number, and item number on each sheet. We recommend that you keep a photocopy of your completed form for your records.

Privacy Act Statement The Office of Personnel Management is authorized to request this information under sections 1302, 3301, 3304, 3328, and 8716 of title 5, U. S. Code. Section 1104 of title 5 allows the Office of Personnel Management to delegate personnel management functions to other Federal agencies. If necessary, and usually in conjunction with another form or forms, this form may be used in conducting an investigation to determine your suitability or your ability to hold a security clearance, and it may be disclosed to authorized officials making similar, subsequent determinations.

Your Social Security Number (SSN) is needed to keep our records accurate, because other people may have the same name and birth date. Public Law 104-134 (April 26, 1996) asks Federal agencies to use this number to help identify individuals in agency records. Giving us your SSN or any other information is voluntary. However, if you do not give us your SSN or any other information requested, we cannot process your application. Incomplete addresses and ZIP Codes may also slow processing.

ROUTINE USES: Any disclosure of this record or information in this record is in accordance with routine uses found in System Notice OPM/GOVT-1, General Personnel Records. This system allows disclosure of information to: training facilities; organizations deciding claims for retirement, insurance, unemployment, or health benefits; officials in litigation or administrative proceedings where the Government is a party; law enforcement agencies concerning a violation of law or regulation; Federal agencies for statistical reports and studies; officials of labor organizations recognized by law in connection with representation of employees; Federal agencies or other sources requesting information for Federal agencies in connection with hiring or retaining, security clearance, security or suitability investigations, classifying jobs, contracting, or issuing licenses, grants, or other benefits; public and private organizations, including news media, which grant or publicize employee recognitions and awards; the Merit Systems Protection Board, the Office of Special Counsel, the Equal Employment Opportunity Commission, the Federal Labor Relations Authority, the National Archives and Records Administration, and Congressional offices in connection with their official functions; prospective non-Federal employers concerning tenure of employment, civil service status, length of service, and the date and nature of action for separation as shown on the SF 50 (or authorized exception) of a specifically identified individual; requesting organizations or individuals concerning the home address and other relevant information on those who might have contracted an illness or been exposed to a health hazard; authorized Federal and non-Federal agencies for use in computer matching; spouses or dependent children asking whether the employee has changed from a self-and-family to a self-only health benefits enrollment; individuals working on a contract, service, grant, cooperative agreement, or job for the Federal government; non-agency members of an agency's performance or other panel; and agency-appointed representatives of employees concerning information issued to the employees about fitness-for-duty or agency-filed disability retirement procedures.

Public Burden Statement Public burden reporting for this collection of information is estimated to vary from 5 to 30 minutes with an average of 15 minutes per response, including time for reviewing instructions, searching existing data sources, gathering the data needed, and completing and reviewing the collection of information. Send comments regarding the burden estimate or any other aspect of the collection of information, including suggestions for reducing this burden, to the U.S. Office of Personnel Management, Reports and Forms Manager (3206-0182), Washington, DC 20415-7900. The OMB number, 3206-0182, is valid. OPM may not collect this information, and you are not required to respond, unless this number is displayed.

U.S. Office of Personnel Management

5 U.S.C. 1302, 3301, 3304, 3328 & 8716

Optional Form 306 Revised August 2023

Previous editions obsolete and unusable

General Information

1. FULL NAME (Provide your full name. If you have only initials in your name, provide them and indicate "Initial only". If you do not have a middle name, indicate "No Middle Name". If you are a "Jr.," "Sr.," etc. enter this under Suffix. First, Middle, Last, Suffix)

2. SOCIAL SECURITY NUMBER 3a. PLACE OF BIRTH (Include city and state or country)

3b. ARE YOU A U.S. CITIZEN?

YES NO (If "NO", provide country of citizenship)

4. DATE OF BIRTH (MM / DD / YYYY)

5. OTHER NAMES EVER USED (For example, maiden name, nickname, etc.) 6. PHONE NUMBERS (Include area codes)

Day

Night

Selective Service Registration If you are a male born after December 31, 1959, and are at least 18 years of age, civil service employment law (5 U.S.C. 3328) requires that you must register with the Selective Service System, unless you meet certain exemptions.

7a. Were you born a male after December 31, 1959? YES NO (If "NO", proceed to 8.)

7b. Have you registered with the Selective Service System? YES (If "YES", proceed to 8.) NO (If "NO", proceed to 7c.)

7c. If "NO," describe your reason(s) in item 16.

(*This form may also be used to assess fitness for federal contract employment)

Military Service

8. Have you ever served in the United States military? YES (If "YES", provide information below) NO

If your only active duty was training in the Reserves or National Guard, answer "NO.”

If you answered "YES," list the branch, dates, and type of discharge for all active duty.

Branch From (MM/DD/YYYY) To (MM/DD/YYYY) Type of Discharge

Background Information For all questions, provide all additional requested information under item 16 or on attached sheets. The circumstances of each event you list will be considered. However, in most cases you can still be considered for Federal jobs.

For questions 9,10, and 11, your answers should include convictions resulting from a plea of nolo contendere (no contest), but omit (1) traffic fines of $300 or less, (2) any violation of law committed before your 16th birthday, (3) any violation of law committed before your 18th birthday if finally decided in juvenile court or under a Youth Offender law, (4) any conviction set aside under the Federal Youth Corrections Act or similar state law, and (5) any conviction for which the record was expunged under Federal or state law .

9. During the last 7 years, have you been convicted, been imprisoned, been on probation, or been on parole?

(Includes felonies, firearms or explosives violations, misdemeanors, and all other offenses.) If "YES," use item 16 to provide the date, explanation of the violation, place of occurrence, and the name and address of the police department or court involved.

YES NO

10. Have you been convicted by a military court-martial in the past 7 years? (If no military service, answer "NO.") If "YES," use item 16 to provide the date, explanation of the violation, place of occurrence, and the name and address of the military authority or court involved.

YES NO

11. Are you currently under charges for any violation of law? If "YES," use item 16 to provide the date, explanation of the charges, place of occurrence, and the name and address of the police department or court involved.

YES NO

12. During the last 5 years, have you been fired from any job for any reason, did you quit after being told that you would be fired, did you leave any job by mutual agreement because of specific problems, or were you debarred from Federal employment by the Office of Personnel Management or any other Federal agency? If "YES," use item 16 to provide the date, an explanation of the problem, reason for leaving, and the employer's name and address.

YES NO

13. Are you delinquent on any Federal debt? (Includes delinquencies arising from Federal taxes, loans, overpayment of benefits, and other debts to the U.S. Government, plus defaults of Federally guaranteed or insured loans such as student and home mortgage loans.) If "YES," use item 16 to provide the type, length, and amount of the delinquency or default, and steps that you are taking to correct the error or repay the debt.

YES NO

U.S. Office of Personnel Management

5 U.S.C. 1302, 3301, 3304, 3328 & 8716

Optional Form 306 Revised August 2023

Previous editions obsolete and unusable

(*This form may also be used to assess fitness for federal contract employment)

Additional Questions

14. Do any of your relatives work for the agency or government organization to which you are submitting this form?

(Include: father, mother, husband, wife, son, daughter, brother, sister, uncle, aunt, first cousin, nephew, niece, father-in-law, mother-in-law, son-in-law, daughter-in-law, brother-in-law, sister-in-law, stepfather, stepmother, stepson, stepdaughter, stepbrother, stepsister, half-brother, and half-sister.) If "YES," use item 16 to provide the relative's name, relationship, and the department, agency, or branch of the Armed Forces for which your relativeworks.

YES NO

15. Do you receive, or have you ever applied for, retirement pay, pension, or other retired pay based on military, Federal civilian, or District of Columbia Government service?

YES NO

Continuation Space / Agency Optional Questions

16. Provide details requested in items 7 through 15 and 18c in the space below or on attached sheets. Be sure to identify attached sheets with your name, Social Security Number, and item number, and to include ZIP Codes in all addresses. If any questions are printed below, please answer as instructed (these questions are specific to your position and your agency is authorized to ask them).

Certifications / Additional Questions APPLICANT: If you are applying for a position and received a tentative/conditional job offer or have not yet been selected, carefully review your answers on this form and any attached sheets.

APPOINTEE: If you are being appointed, carefully review your answers on this form and any attached sheets, including any other application materials that your agency has attached to this form. If any information requires correction to be accurate as of the date you are signing, make changes on this form or the attachments and/or provide updated information on additional sheets, initialing and dating all changes and additions.

When this form and all attached materials are accurate, read item 17, complete 17b, read 18, and answer 18a, 18b, and 18c as appropriate.

17. I certify that, to the best of my knowledge and belief, all of the information on and attached to this Declaration for Federal Employment, including any attached application materials, is true, correct, complete, and made in good faith. I understand that a false or fraudulent answer to any question or item on any part of this declaration or its attachments may be grounds for not hiring me, or for firing me after I begin work, and may be punishable by fine or imprisonment. I understand that any information I give may be investigated for purposes of determining eligibility for Federal employment as allowed by law or Presidential order. I consent to the release of information about my ability and fitness for Federal employment by employers, schools, law enforcement agencies, and other individuals and organizations to investigators, personnel specialists, and other authorized employees or representatives of the Federal Government. I understand that for financial or lending institutions, medical institutions, hospitals, health care professionals, and some other sources of information, a separate specific release may be needed, and I may be contacted for such a release at a later date.

17a. Applicant's Signature: Date:

(MM / DD / YYYY)

17b. Appointee's Signature: Date:

(MM / DD / YYYY)

18. Appointee (Only respond if you have been employed by the Federal Government before): Your elections of life insurance during previous Federal employment may affect your eligibility for life insurance during your new appointment. These questions are asked to help your personnel office make a correct determination.

18a. When did you leave your last Federal job? Date:

(MM / DD / YYYY)

18b. When you worked for the Federal Government the last time, did you waive Basic Life Insurance or any type of optional life insurance?

YES NO DO NOT KNOW

18c. If you answered "YES" to item 18b, did you later cancel the waiver(s)? If your answer to item 18c is "NO," use item 16 to identify the type(s) of insurance for which waivers were not canceled.

YES NO DO NOT KNOW

U.S. Office of Personnel Management

5 U.S.C. 1302, 3301, 3304, 3328 & 8716

Optional Form 306 Revised August 2023

Previous editions obsolete and unusable

Appointing Officer:

Enter Date of Appointment or Conversion

MM / DD / YYYY

DEPARTMENT OF VETERANS AFFAIRS

PERSONNEL SECURITY ADJUDICATION CENTER

Self Certification of Continuous Service

I hereby certify my break in service from my last federal employment is indicated by the block checked below.

I have NOT had a break in service.

My break in service was less than 60 days.

My break in service was greater than 60 days, but less than two (2) years. (You are required to submit the OF 306, Declaration for Federal

Employment, with this form.)

My break in service is greater than two (2) years; or I have never had federal employment as defined above.

Print Name: Social Security Number:

Signature: Date:

VA Personnel Security/HR Use Only:

Current Investigation in PIPS: Date:

Risk level of current position: Verified by:

(Check One)

Federal employment is defined as any branch of the United States military (Active, Guard or Reserve), federal government civilian employee (any federal government agency), or a contractor working for the federal government.

Self Certification of Continuous Service Form Revised February 28, 2020

Previous Versions are Obsolete