Draft PWS- LWSC IDIQ Medical Surveillance 11-6-2020.pdf

Performance Work Statement (PWS) Medical Surveillance Services for The Lake Washington Ship Canal

Seattle, WA 98107

Table of Contents

SECTION 1: GENERAL INFORMATION/DESCRIPTION OF SERVICES

1. Introduction:

1.1. Background:

1.2. Purpose/Objective:

1.3. Applicable Publications:

1.4. Ordering Procedures:

1.5. Hours of Operation:

1.6. Recognized Holidays:

1.7. Place of Performance:

1.8. Government Furnished Equipment:

1.9. Ordering Period:

1.10. Direct and Indirect Costs:

1.11. Safety Requirements:

SECTION 2: PERFORMANCE REQUIREMENTS AND RESPONSIBILITIES

2. CONTRACT ADMINISTRATION:

2.1. Insurance:

2.2. Privacy:

2.3. Staffing / Testing Standards:

2.4. Record Keeping:

2.5. Personal Protective Equipment:

2.6. Government Key Personnel:

2.7. Contractor Point of Contact:

2.8. Post Award Conference / Periodic Meetings:

SECTION 3: SCOPE OF WORK

3. SPECIFIC TASKS:

3.1. Estimated Workload:

3.2. Clearance Letters:

3.3. Submittal Invoices:

SECTION 4: APPENDIXES AND ATTACHMENTS

DEFINITIONS AND ACRONYMS:

SECTION 1: GENERAL INFORMATION/DESCRIPTION OF SERVICES

1. Introduction: This is a non-personal health care services single award task order (SATOC) indefinite quantity, indefinite delivery (IDIQ) contract (see FAR 52.216-22) to provide medical testing services for the U.S Army Corps of Engineers (USACE) employees at The Lake Washington Ship Canal (LWSC) in Seattle, WA. The Government may evaluate the quality of professional and administrative services provided, but retain no control over the medical professional aspects of services rendered such as testing procedures, etc. The Contractor will provide Board Certified Occupational Health Physician(s), supervision, all labor, tools, materials, equipment, and incidentals required to conduct the Medical Surveillance Examination / Occupational Health Services.

The guidelines and conditions identified below represent the Government’s minimum requirements and do not relieve the Contractor of responsibility of complying with all federal, state and local laws pertaining to the performance and accomplishment of the services identified throughout this contract.

Any reference to a federal, state or local law or regulation within this contract is for emphasis only and does not relieve the Contractor of the obligation to be aware of and comply with all applicable federal, state and local county laws and regulations.

1.1. Background: The U.S. Army Corps of Engineers (USACE) is required to provide medical surveillance and clearance testing services for their employees for safety/readiness purposes. Medical surveillance testing services and examinations include pre-employment, medical surveillance and periodic medical clearance examinations of employees to meet regulatory requirements based on employee job descriptions, exposures, and job tasks. USACE uses the guidelines of 29 CFR 1910, EM 385-1-1, ER- 385-1-40 and ER 385-1-89.

1.2. Purpose/Objective: The purpose of the Occupational Medical Surveillance Examination Program is to provide job-related Medical Surveillance Examinations and Occupational Health Services to LWSC employees who are or could potentially be exposed to health hazards in the work environment. The examination shall include personnel assigned to positions requiring specific standards of physical fitness.

All medical reports/results require a review by a doctor who is certified or board eligible in Occupational Health. This requirement shall be maintained for the length of the contract.

1.3. Applicable Publications:

- EM 385-1-1 (2014), USACE Safety and Health Requirements Manual

- 29 CFR 1910, Occupational Safety and Health Administration

- ER 385-1-40, Occupational Health Program

- ER 385-1-89, Hearing Conservation Program

1.4. Ordering Procedures: Task orders will be issued by the Government as the need arises during the contract ordering period. Individual task orders under this contract will describe actual services to be performed for specific services. The Government makes no guarantee as to the total amount of services to be required and reserves the right to require no services during the ordering period.

The Contractor is advised not to perform any services under this contract resulting in a change of work or services that affects the price of a task order unless previously negotiated and/or approved by the Contracting Officer (KO).

1.5. Hours of Operation: The Contractor is responsible for setting their own hours of business.

However, the Contractor must provide adequate support to achieve required performance objectives of section 3 for the duration of the performance period. The Government will schedule appointments prior to sending employees during normal hours of business: Monday through Friday, 0630-1500 (Pacific Time).

1.6. Recognized Holidays: The Contractor is not required to conduct work on the following Federal holidays:

New Year’s Day Labor Day Martin Luther King Jr.’s Birthday Columbus Day President’s Day Veteran’s Day Memorial Day Thanksgiving Day Independence Day Christmas Day

1.7. Place of Performance: Most of the work under this contract will be performed at the contractor’s facility within 10 miles of LWSC.

As an option, a portion of this work will be performed at LWSC at a location determined by the LWSC Safety Officer.

LWSC is located at the following address: Lake Washington Ship Canal, 3015 NW 54th ST., Seattle, WA 98107-4299.

1.8. Government Furnished Equipment: The Government will provide facility space at The Lake Washington Ship Canal to be used to fulfill the requirements as outlined in this document.

1.9. Ordering Period: This contract has one (1) twelve (12) month base year and three (3) twelve (12) month option year periods.

Base Year: 15 January 2021 – 14 January 2022 Option Year 1: 15 January 2022 – 14 January 2023 Option Year 2: 15 January 2023 – 14 January 2024 Option Year 3: 15 January 2024 – 14 January 2025

1.10. Direct and Indirect Costs: All costs incurred by the Contractor related to the performance of contract work are the responsibility of the Contractor. All travel costs that may be required during the duration of this contract will be the responsibility of the Contractor.

1.11. Safety Requirements: The Contractor shall conform to applicable OSHA, and State of Washington, standards, as well as USACE of Engineers Safety Requirements Manual (EM 385-1-1), available here: EM 385-1-1.pdf. Compliance with Occupational Safety and Health Act (OSHA), and other applicable laws and regulations for the protection of Contractor employees is exclusively the Contractor’s obligation, and the Government will assume no liability or responsibility for the Contractor’s compliance or non-compliance with such responsibilities.

1.11.1. Safety Plan: A safety plan may be required for some task orders. The plan shall include, but not be limited to, description of steps that will be taken to comply with USACE safety requirements as outlined in EM 385-1-1.

1.12. Organization Conflict of Interest: Contractor and subcontractor personnel performing work under this contract may receive, have access to or participate in the development of proprietary or source selection information (e.g., cost or pricing information, budget information or analyses, specifications or https://www.publications.usace.army.mil/Portals/76/Publications/EngineerManuals/EM_385-1-1.pdf work statements, etc.) or perform evaluation services which may create a current or subsequent Organizational Conflict of Interests (OCI) as defined in FAR Subpart 9.5.

1.13. Security Requirements: All contractor and all associated sub-contractor employees shall comply with applicable installation, facility and area commander installation/facility access and local security policies and procedures (provided by government representative). The contractor shall also provide all information required for background checks to meet installation/facility access requirements to be accomplished by installation Provost Marshal Office, Director of Emergency Services or Security Office.

Contractor workforce must comply with all personal identity verification requirements (FAR clause 52.204-9, Personal Identity Verification of Contractor Personnel) as directed by DOD, HQDA and/or local policy. In addition to the changes otherwise authorized by the changes clause of this contract, should the Force Protection Condition (FPCON) at any installation or facility change, the Government may require changes in contractor security matters or processes.

The Contractor must pre-screen Candidates using the E-verify Program (http://www.uscis.gov/e-verify) website to meet the established employment eligibility requirements. The Vendor must ensure that the Candidate has two valid forms of Government issued identification prior to enrollment to ensure the correct information is entered into the E-verify system. An initial list of verified/eligible Candidates must be provided to the COR no later than 3 business days after the initial contract award." *When contracts are with individuals, the individuals will be required to complete a Form I-9, Employment Eligibility Verification, with the designated Government representative. This Form will be provided to the Contracting Officer and shall become part of the official contract file.

http://www.uscis.gov/e-verify

SECTION 2: PERFORMANCE REQUIREMENTS AND RESPONSIBILITIES

2. CONTRACT ADMINISTRATION: The Government will evaluate the Contractor’s performance under this contract in accordance with the Quality Assurance Surveillance Plan (QASP). The QASP will be used as a basis for evaluation. Failure to adequately complete any service or submittal to at least a satisfactory level of quality and timeliness may result in repeat of work, a poor performance evaluation, or both. The QASP is primarily focused on what the Government will do to ensure that the Contractor has performed in accordance with the performance standards. It defines how the performance standards will be applied, the frequency of surveillance, and the minimum acceptable defect rate(s).

2.1. Insurance: This contract is for “Non-Personal” Health Care “Services”, as defined in 37.101. In accordance with FAR Part 37.4 the Government may enter a non-personal health care services contract with physicians, dentists and other health care providers under authority of 10 U.S.C. 2304 and 41 U.S.C.

253. The Government shall evaluate the quality of professional and administrative services provided, while the Government retains no control over the medical, professional aspects of services rendered. The Contractor will indemnify the Government for any liability producing act or omission by the Contractor, its employees and agents occurring during contract performance. The Contractor will maintain medical liability insurance, in a coverage amount acceptable to the Contracting Officer, which is not less than the amount normally prevailing within the local community for the medical specialty concerned. The Contractor is required to ensure that its subcontractors, if any, for provisions of health care services, contain the requirements of the clause at 52.237-7, Indemnification and Medical Liability Insurance, including the maintenance of medical liability insurance. The contractor, upon request by the Contracting Officer, shall furnish prior to contract award evidence of its insurability concerning the medical liability insurance required by this clause.

2.2. Privacy: The Contractor shall ensure that all findings are clearly recorded on Government or other approved forms and are protected by Privacy Act of 1974 and Health Insurance Portability and Accountability Act of 1996 (HIPAA) mandated safeguards to ensure confidentiality of health information.

Contractor shall identify all medical records with the employee’s full name, social security number, date of birth, and the name of the employee’s workplace or facility at a minimum. The contractor shall ensure work / health history forms and medical reports are complete and legible (typed / printed).

2.3. Staffing / Testing Standards: All medical surveillance and clearance examinations reports shall be reviewed, signed, and approved by a physician that is Board Certified or Board eligible in Occupational Medicine. Contractor shall ensure all procedures are conducted in accordance with applicable American Board of Occupational and Environmental Medicine (ABOEM), American Association of Occupational Health Nurses (AAOHN), U.S. Department of Labor, Occupational Safety and Health Administration (OSHA), and the National Institute for Occupational Safety and Health (NIOSH) Standards.

2.4. Record Keeping: The contractor shall act as the medical records custodian for all medical records as generated by the performance of this contract for the duration of this contract. Potential duties to include answering document requests and holding a complete file of all records at the contractor’s facility.

At the conclusion of this contract, the Government shall provide the contractor a forwarding point of contact for the transference of all files or records.

2.5. Personal Protective Equipment: Contractor shall furnish and assure healthcare workers are provided with the appropriate PPE such as, but not limited to gloves, protective eyewear, and masks, where there is a potential for exposure to blood or other potentially infectious materials.

2.6. Government Key Personnel:

USACE Contracting Officer (KO) – Identified person is responsible for the oversight and execution of this contract.

LWSC Safety Officer – Identified person serves as the Contractor’s main point of contact for the execution of this contract. Duties to include scheduling exams and receipt of clearance letters as required in part 3 of this PWS. Additionally, this person maintains written and oral communications with the Contractor concerning technical aspects of the contract, and monitor Contractor’s performance.

USACE Chief of Seattle District Safety Office – Identified person shall receive a copy of every clearance letter as required by part 3 of this PWS.

2.7. Contractor Point of Contact: The Contractor shall provide a point of contact who shall be responsible for assisting in the scheduling of exams/appointments and replying to any inquiries that may arise as result of the work performed by this contract. The name of this person and an alternate who shall act for the Contractor when the point of contact is absent shall be designated in writing to the contracting officer. The Contractor shall immediately notify the contracting officer and the LWSC Safety Officer if the Contractor’s point of contact or alternate change.

2.8. Post Award Conference / Periodic Meetings: The Contractor agrees to attend any post award conference convened by the contracting activity or contract administration office in accordance with Federal Acquisition Regulation Subpart 42.5. Government personnel, as appropriate, may meet periodically with the Contractor to review the Contractor's performance. These meetings shall be at no additional cost to the Government.

SECTION 3: SCOPE OF WORK

3. SPECIFIC TASKS: No work shall be performed prior to the award of a task order. Task orders may include any of the tasks set out below for management of medical surveillance on LWSC. Under this contract, some, none, or all the tasks presented herein may be ordered for delivery to the Government.

Employees will provide the doctor with specific guidance relevant to their personal exposures and content of their exam.

3.1. Estimated Workload: Medical Surveillance, clearance testing, and lab services as required by this contract are the following:

1. Hazardous Waste Worker, estimated quantity: 2

2. Pesticide Applicator, estimated quantity: 1

3. Asbestos Worker, estimated quantity: 0

4. Crane Operator, estimated quantity: 2

5. Commercial Drivers’ License, estimated quantity: 3

6. Coast Guard Licenses Holders – Platforms, Tugs, or Commercial Watercraft Pilots or Captains, estimated quantity: 0

7. Employees Exposed to Lead, estimated quantity: 2

8. Employees with Potential Bloodborne Pathogen Exposures, estimated quantity: 0

9. Respirator User, estimated quantity: 12

10. Employees Exposed to Chromium VI, estimated quantity: 1

11. Employees Exposed to Vision Hazards or Requiring Visual Acuity, estimated quantity: 13

12. (Non-ionizing) Radiation Worker, estimated quantity: 0

13. Lock Operator, estimated quantity: 0

14. Welder, estimated quantity: 2

15. Painter, estimated quantity: 0

16. Arbovirus Exposure, estimated quantity: 0

17. Pre-placement exam and periodic surveillance for exposure to Be, Cd, and other heavy metals, estimated quantity: TBD

18. Employees Exposed to Noise, estimated quantity: 14

19. Pre-placement Exam for New or Transfer Employees and annual exam there after (for the trades), estimated quantity: TBD

20. Post treatment after an exposure to blood borne pathogens, estimated quantity: TBD

3.2. Clearance Letters: All the above tasks require a medical clearance letter following the exam within 3 weeks of the date of the exam EXCEPT for the following:

Employee Exposed to Noise. If a Significant Threshold Shift is detected during this task, the Project Safety Officer must be notified within 10 calendar days so that a follow up exam can be scheduled.

Pre-placement Exam for New or Transfer Employees. This task requires a medical clearance letter within 5 calendar days of the date of the exam.

Post treatment after an exposure to blood borne pathogens. No clearance letter required

The original copy of all clearance letters shall be sent by hard copy US Mail to the Project Safety Officer and a copy shall be sent via encrypted e-mail to the USACE Seattle District Safety Office Chief and the Project Safety Officer:

Project Safety Officer: Mr. Osman Huseny, Osman.Huseny@usace.army.mil, Lake Washington Ship Canal, 3015 NW 54th ST., Seattle, WA 98107-4299

USACE Seattle District Safety Office Chief: Mr. Richard Perry, Richard.A.Perry@usace.army.mil, 4735 E Marginal Way S BLDG 1202, Seattle, WA 98134

3.3. Submittal Invoices: The Contractor shall furnish invoices as required to the LWSC Safety Officer; evidencing performance of work done under this contract. The invoice must include the following information:

Contract number;

Task Order number;

Project name;

Amount for each line item, Line item description with CPT code.

SECTION 4: APPENDIXES AND ATTACHMENTS

Appendix A: Medical Surveillance Examination – Procedure Request Form Appendix B: Template Medical Questionnaire Attachment 1: Optional Form (OF) 178: Certificate of Medical Examination Attachment 2: Quality Assurance and Performance Requirement Summary

APPENDIX A: Medical Surveillance Examination – Procedure Request Form

Employee Name: _______________________

Date: ______________

Clearances Required (Check for Yes)

Respirator Commercial Driver’s License

Crane Operator U.S. Coast Guard

Name of Test Current Procedural Terminology (CPT)

Check for Yes Leave blank for No

Work-related exam w/ work history 99456

DoT Commercial Driver License exam 99214

Audiogram 92552

Lab-CBC w/ differential

(not needed when a General Health Panel is ordered)

85025

Visual Acuity 99173

Chest X-Ray 2 Views (asbestos) 71020

X-Ray B-reading (asbestos) 71250

General Health Panel

(Complete Blood Count(CBC), Comprehensive Metabolic Count (CMP) & Thyroid tests.

80050

Thyroxine 84439

Urinalysis w/ microscopy 81015

Cadmium 82300

Venipuncture 36415

Lab - Heavy Metal Blood

(Use specific heavy metal quantitative code instead of 83018 when available.)

83018

Zinc 84630

Chromium 82495

Lab – Nickel Blood Test 83885

Hep B – Adult 90746

Hep A - Adult 90632

Tetanus / Diptheria (Tdap) 90715

Lead & Zinc OSHA 84202

Flu Shot

The following tests shall be completed only after receiving approval from the Administrative Officer or their designee.

Test Current Procedural Terminology (CPT)

Authorization received (Y/N)

EKG Complete 93000

Cardiovascular Stress Test 93015

Safety Officer: ___________ _____________ Date: ______

When completed the Safety Officer will provide a scanned copy to the District Safety and Occupational Health Office and the employee shall present the completed form to the medical staff at the time of their examination.

APPENDIX B: Template Medical Questionnaire

Medical Questionnaire for Respiratory Protection

INITIAL MEDICAL QUESTIONNAIRE

1. Name ________________________________________________________________

2. Social Security Number # ____________________________________________

3. Present occupation __________________________________________________

4. Project _______________________________________________________________

5. Address _____________________________________________________________

6. Telephone number ____________________________________________________

7. Interviewer _________________________________________________________

8. Date ________________________________________________________________

9. Date of Birth (month/Day/Year): ___________________________________________

10. Place of Birth ______________________________________________________

11. Sex (Circle): Male Female

12. Marital status (Circle): Single Separated Married Divorced Widowed

13. Race (circle): White Hispanic Black Native American Asian Other

14. What is the highest grade completed in school? _____________________

OCCUPATIONAL HISTORY

15. Have you ever worked full time (30 hours per week or more) for 6 months or more? Yes No

IF YES: A. Have you ever worked for a year or more in any dusty job? Yes No Does Not Apply

Specify job/industry _______________ Total Years Worked __________

Was exposure: Mild Moderate Severe

B. Have you ever been exposed to gas or chemical vapors in your work? Yes No Specify job/industry ______________________ Total Years Worked ___

Was exposure: Mild Moderate Severe

C. What has been your usual occupation or job -- the one you have worked at the longest?

Job occupation _____________________________________________

Number of years employed in this occupation ____________________

Position/job title ____________________________________________

Business, field or industry _____________________________________

(Record on lines the years in which you have worked in any of these industries, e.g. 1960-1969)

PAST MEDICAL HISTORY

16. Do you consider yourself to be in good health? Yes / No If "NO" state reason:

17. Have you any defect of vision? Yes / No If "YES" state nature of defect:

18. Have you any hearing defect? Yes / No If "YES" state nature of defect:

Yes No Are you suffering from or have you ever suffered from Epilepsy/seizures?

Are you suffering from or have you ever suffered from Rheumatic fever?

Are you suffering from or have you ever suffered from Kidney disease?

Are you suffering from or have you ever suffered from Bladder disease?

Are you suffering from or have you ever suffered from Diabetes?

Are you suffering from or have you ever suffered from Jaundice?

CHEST COLDS AND CHEST ILLNESSES

19. If you get a cold, does it "usually" go to your chest? (Usually means more than 1/2 the time)

Yes No Don't get colds

20. During the past 3 years, have you had any chest illnesses that have kept you off work, indoors at home, or in bed? Yes No

IF YES: A. Did you produce phlegm with any of these chest illnesses? Yes No Does Not Apply

B. In the last 3 years, how many such illnesses with (increased) phlegm did you have which lasted a week or more?

Number of illnesses _______ No such illnesses ________

21. Did you have any lung trouble before the age of 16? Yes No

22. Have you ever had any of the following?

A. Attacks of bronchitis? Yes No

IF YES: Was it confirmed by a doctor? Yes No

At what age was your first attack? Age in Years ______

Have you ever worked: YES NO Years In a mine?

In a quarry?

In a foundry?

In a pottery?

In a cotton, flax or hemp mill?

With asbestos?

B. Pneumonia (include bronchopneumonia)? Yes No

At what age did you first have it? Age in Years ______

C. Hay Fever? Yes No

At what age did it start? Age in Years ______

23. Have you ever had chronic bronchitis? Yes No

IF YES: A. Do you still have it? Yes No

B. Was it confirmed by a doctor? Yes No

C. At what age did it start? Age in Years ______

24. Have you ever had emphysema? Yes No

C. At what age did it start? Age in Years _______

25. Have you ever had asthma? Yes No

C. At what age did it start? Age in Years ______

D. If you no longer have it, at what age did it stop? Age stopped _____

26. Have you ever had?

A. Any other chest illness? Yes No If yes, please specify ___________________________________________

B. Any chest operations? Yes No If yes, please specify ___________________________________________

C. Any chest injuries? Yes No

If yes, please specify ___________________________________________

27. Has a doctor ever told you that you had heart trouble? Yes No

IF YES: Have you ever had treatment for heart trouble in the past 10 years?

28. Has a doctor told you that you had high blood pressure? Yes No

IF YES: Have you had any treatment for high blood pressure (hypertension) in the past 10 years? Yes No

29. When did you last have your chest X-rayed? (Year) _____________________________

30. Where did you last have your chest X-rayed (if known)?

What was the outcome? _______________________________________________

FAMILY HISTORY

31. Were either of your natural parents ever told by a doctor that they had a chronic lung condition such as:

Father Mother Yes No Don’t know Yes No Don’t know A. Chronic Bronchitis B. Emphysema

C. Asthma

D. Lung Cancer

E. Other chest conditions F. Is parent currently alive G. Please specify Age if living:

Age at Death:

Don’t know

Age if living:

Age at Death:

Don’t know

H. Please specify the cause of death

COUGH

32. Do you usually have a cough? (Count a cough with first smoke or on first going out of doors. Exclude clearing of throat.) (If no, skip to question 32 C.) Yes No

A. Do you usually cough as much as 4 to 6 times a day 4 or more days out of the week? Yes No

B. Do you usually cough at all on getting up or first thing in the morning? Yes No

C. Do you usually cough at all during the rest of the day or at night? Yes No

IF YES TO ANY OF ABOVE (34, A, B, OR C), ANSWER THE FOLLOWING. IF NO TO ALL, CHECK

____ DOES NOT APPLY AND SKIP TO QUESTION 33.

D. Do you usually cough like this on most days for 3 consecutive months or more during the year? Yes No

E. For how many years have you had the cough? Number of years ______

33. Do you usually bring up phlegm from your chest? (Count phlegm with the first smoke or on first going out of doors. Exclude phlegm from the nose. Count swallowed phlegm.) (If no, skip to 33 B)

A. Do you usually bring up phlegm like this as much as twice a day 4 or more days out of the week? Yes No

B. Do you usually bring up phlegm at all on getting up or first thing in the morning? Yes No

C. Do you usually bring up phlegm at all on during the rest of the day or at night? Yes No

IF YES TO ANY OF THE ABOVE (33, A, B, OR C), ANSWER THE FOLLOWING: IF NO TO ALL,

CHECK

_____ DOES NOT APPLY AND SKIP TO 36.

D. Do you bring up phlegm like this on most days for 3 consecutive months or more during the year?

Yes No Does Not Apply

E. For how many years have you had trouble with phlegm? Number of years ___ Does not apply

EPISODES OF COUGH AND PHLEGM

34. Have you had periods or episodes of (increased*) cough and phlegm lasting for 3 weeks or more each year?*(For persons who usually have cough and/or phlegm) Yes No

IF YES: A. For how long have you had at least 1 such episode per year?

Number of years ______

WHEEZING

35. Does your chest ever sound wheezy or whistling…

A. When you have a cold? Yes No

B. Occasionally apart from colds? Yes No

C. Most days or nights? Yes No

IF YES TO A, B, or C: For how many years has this been present?

Number of years _____ Does not apply

36. Have you ever had an attack of wheezing that has made you feel short of breath? Yes No IF YES: A. How old were you when you had your first such attack? Age in years _____

B. Have you had 2 or more such episodes? Yes NO

C. Have you ever required medicine or treatment for the(se) attack(s)? Yes No

BREATHLESSNESS

37. If disabled from walking by any condition other than heart or lung disease, please describe and proceed to question 39.

Nature of condition(s):

38. Are you troubled by shortness of breath when hurrying on the level or walking up a slight hill?

Yes No IF YES: A. Do you have to walk slower than people of your age on the level because of breathlessness?

B. Do you ever have to stop for breath when walking at your own pace on the level? Yes No

C. Do you ever have to stop for breath after walking about 100 yards (or after a few minutes) on the level? Yes No

D. Are you too breathless to leave the house or breathless on dressing or climbing one flight of stairs? Yes No

TOBACCO SMOKING

39. Have you ever smoked cigarettes? (No means less than 20 packs of cigarettes or 12 oz. of tobacco in a lifetime or less than 1 cigarette a day for 1 year.) Yes No

IF YES: A. Do you now smoke cigarettes (as of one month ago) Yes No

B. How old were you when you first started regular cigarette smoking? Age in years___

C. If you have stopped smoking cigarettes completely, how old were you when you stopped? Age stopped___ Check if still smoking ___

D. How many cigarettes do you smoke per day now?

Cigarettes per day___ Does not apply___

E. On the average of the entire time you smoked, how many cigarettes did you smoke per day?

Cigarettes per day___

F. Do or did you inhale the cigarette smoke?

Not at all___ Slightly___ Moderately___ Deeply___

40. Have you ever smoked a pipe regularly? (Yes means more than 12 oz. of tobacco in a lifetime.)

IF YES: A. How old were you when you started to smoke a pipe regularly? Age ___

B. If you have stopped smoking a pipe completely, how old were you when you stopped? Age stopped___ Check if still smoking pipe___

C. On the average over the entire time you smoked a pipe, how much pipe tobacco did you smoke per week? ___ oz. per week (a standard pouch of tobacco contains 1 1/2 oz.)

D. How much pipe tobacco are you smoking now?

oz. per week___ Not currently smoking a pipe ___

E. Do you or did you inhale the pipe smoke?

Not at all___ Slightly___ Moderately___ Deeply ___

41. Have you ever smoked cigars regularly? (Yes means more than 1 cigar a week for a year) Yes No

IF YES: A. How old were you when you started smoking cigars regularly? Age _____

B. If you have stopped smoking cigars completely, how old were you when you stopped?

Age ___ Check if you are still smoking cigars___ C. On the average over the entire time you smoked cigars, how many cigars did you smoke per week? Cigars per week ___

D. How many cigars are you smoking per week now?

Cigars per week ___ Check if not smoking cigars currently___

E. Do or did you inhale the cigar smoke?

Not at all___ Slightly___ Moderately___ Deeply___

Signature ____________________________ Date _____________________

DEFINITIONS AND ACRONYMS:

Contracting Officer (KO): The Government employee who is authorized to enter, administer, and/or terminate contracts and make related determinations and findings. The only individual who can legally bind the Government.

Current Procedural Terminology (CPT): Uniform information about medical services and procedures among physicians, coders, patients, accreditation organizations, and payers for administrative, financial, and analytical purposes.

Engineer Manual (EM) 385-1-1 Safety and Health Requirements Manual: This manual prescribes the safety and health requirements for all Corps of Engineers activities and operations and applies to all military, civilian or contractor personnel.

Federal Acquisition Regulation (FAR): The Federal Acquisition Regulation (FAR), 48 CFR Chapter 1, is the principal set of rules in the Federal Acquisition Regulation System. The FAR System governs the "acquisition process" by which the federal Government purchases (acquires) goods and services.

Health Insurance Portability and Accountability Act (HIPPA) of 1996: Public Law 104-191; U.S. law designed to provide privacy standards to protect patients’ medical records and other health information provided to health plans, doctors, hospitals and other health care providers.

Industrial Hygiene (IH): The science and art devoted to anticipation, recognition, evaluation, prevention and control of those environmental factors or stresses arising in or from the workplace or the community that may cause sickness, impaired health and well-being, or significant discomfort among workers.

Medical Surveillance: The ongoing, systematic collection, analysis and interpretation of data derived from instances of medical care or medical evaluation, and the reporting of population-based information for characterizing and countering threats to a population’s health, well-being and performance (see

DODD 6490.02E).

Position Hazardous Assessment (PHA): A detailed list of the various components of an employee’s work, including a description of each task, an analysis of the inherent hazards of performing the task and a list of the control measures applied to protect the worker from hazards.

Personal Identifiable Identification (PII): Any representation of information that permits the identity of an individual to whom the information applies to be reasonably inferred by either direct or indirect means.

Quality Assurance: The Government's procedures to verify that services being performed by the Contractor are performed according to acceptable standards.

Quality Assurance Surveillance Plan (QASP): The organized written document specifying the methods and procedures the Government will use to ensure it receives the services/products under this contract as identified in the Performance Work Statement (PWS).

Qualified Occupational Health Physician: A licensed and Bord Eligible/Board Certified Doctor of Medicine or Osteopathy who, by virtue of education, specialized training and experience, has acquired a minimum of five (5) years and be knowledgeable of regulations and resources relating to occupation medicine such as OSHA, NIOSH, DoD, DA and ACOEM.

Risk Management: The process of identifying, assessing and controlling risks arising from operational factors and making decisions that balance risk cost with mission benefits.

Sub-Contractor: One that enters a contract with a prime Contractor. The Government does not have privity of contract with the sub-contractor.

Unit of Measure: Standard unit or system of units by means of which a quantity is accounted for and expressed.

Workday: The number of hours per day the Contractor provides services in accordance with the contract.

Work Week: Generally, Monday through Friday unless otherwise agreed upon between Contractor and the Government.