FA4654-14-B-0001_Amendment_1_20140421.pdf

F5D3093352A001

AMENDMENT OF SOLICITATION/MODIFICATION OF CONTRACT

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

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

30-105-04EXCEPTION TO SF 30

APPROVED BY OIRM 11-84

STANDARD FORM 30 (Rev. 10-83)

Prescribed by GSA

FAR (48 CFR) 53.243

The amendment is to change the response date and time to 21 May 2014 at 2:00pm EST. This amendment also incorporates a revised

Performance Work Statement.

1. CONTRACT ID CODE PAGE OF PAGES

J 1 7

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

16C. DATE SIGNED

BY 21-Apr-2014

16B. UNITED STATES OF AMERICA15C. DATE SIGNED15B. CONTRACTOR/OFFEROR

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

8. NAME AND ADDRESS OF CONTRACTOR (No., Street, County, State and Zip Code) X FA4654-14-B-0001

X 9B. DATED (SEE ITEM 11)

31-Jan-2014

10B. DATED (SEE ITEM 13)

9A. AMENDMENT OF SOLICITATION NO.

11. THIS ITEM ONLY APPLIES TO AMENDMENTS OF SOLICITATIONS

X The above numbered solicitation is amended as set forth in Item 14. The hour and date specified for receipt of Offer X is extended, is not extended.

Offer must acknowledge receipt of this amendment prior to the hour and date specified in the solicitation or as amended by one of the following methods:

(a) By completing Items 8 and 15, and returning 1 copies of the amendment; (b) By acknowledging receipt of this amendment on each copy of the offer submitted;

or (c) By separate letter or telegram which includes a reference to the solicitation and amendment numbers. FAILURE OF YOUR ACKNOWLEDGMENT TO BE

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

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

12. ACCOUNTING AND APPROPRIATION DATA (If required)

13. THIS ITEM APPLIES ONLY TO MODIFICATIONS OF CONTRACTS/ORDERS.

IT MODIFIES THE CONTRACT/ORDER NO. AS DESCRIBED IN ITEM 14.

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

CONTRACT ORDER NO. IN ITEM 10A.

B. THE ABOVE NUMBERED CONTRACT/ORDER IS MODIFIED TO REFLECT THE ADMINISTRATIVE CHANGES (such as changes in paying office, appropriation date, etc.) SET FORTH IN ITEM 14, PURSUANT TO THE AUTHORITY OF FAR 43.103(B).

C. THIS SUPPLEMENTAL AGREEMENT IS ENTERED INTO PURSUANT TO AUTHORITY OF:

D. OTHER (Specify type of modification and authority)

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

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

10A. MOD. OF CONTRACT/ORDER NO.

2. AMENDMENT/MODIFICATION NO. 5. PROJECT NO.(If applicable)

6. ISSUED BY

3. EFFECTIVE DATE

21-Apr-2014

CODE

434 CONF/LGC

1900 W MUSTANG AVE

GRISSOM ARB IN 46971-1622

FA4654 7. ADMINISTERED BY (If other than item 6)

4. REQUISITION/PURCHASE REQ. NO.

CODE

See Item 6

FACILITY CODECODE

EMAIL:TEL:

FA4654-14-B-0001

SECTION SF 30 BLOCK 14 CONTINUATION PAGE

SUMMARY OF CHANGES

SECTION SF 1449 - CONTINUATION SHEET

SOLICITATION/CONTRACT FORM

The required response date/time has changed from 21-Feb-2014 02:00 PM to 21-Apr-2014 02:00 PM.

The following have been modified:

BID INSTRUCTIONS

QUESTIONS:

Forward questions to don.roque.1@us.af.mil. No questions will be accepted after 2:00pm EST Friday May 16, 2014.

BID SUBMISSION:

Please submit bids not later than 2:00pm EST Wednesday May 21, 2014. Email bids to don.roque.1@us.af.mil or fax to 765 688 2803. Utilize solictation document pages 1 through 4. Complete Items 17 and 30 on the Standard

Form 1449. Fill in your bid Unit Price and Net Amount for Medical Examination Services Items 0001, 1001, and

2001. All three (3) Medical Examination Services Items must be priced or the bid will be considered unresponsive.

Provide documentation showing current Offeror Representations and Certifications (see http://www.acquisition.gov).

Please include an attachment listing the following information:

1. Company Name and Address

2. POC - Telephone and email

3. CAGE, DUNS, and TIN

PERFORMANCE WORK STATEMENT

PERFORMANCE WORK STATEMENT (PWS)

PHYSICAL EXAMINATIONS FOR NEW APPOINTMENTS, TRANSFER ELIGIBLES,

FITNESS FOR DUTY, OVERSEAS EMPLOYMENT AND OTHER MISCELLANEOUS

PHYSICALS OR TESTING FOR FEDERALLY EMPLOYED CIVILIANS

GRISSOM AIR RESERVE BASE, INDIANA

APRIL 2014

1. Introduction

1.1 Scope. The Contract Physician shall provide all labor, facilities, material, equipment, labs and necessary medical testing and supervision necessary to perform examinations for applicants/employees, to include but not limited to: pre-employment physicals, fitness-for-duty physicals, post-exposure evaluations, employment termination physicals, and overseas employment physicals as specified on Standard Form 78, Certificate of Medical Examination, or other designated forms. The Contract Physician must be Board Certified in Occupational Health to provide physicals. Testing for illegal drugs will not be done as part of annual medical evaluations. Physical examinations and all other procedures will be performed at the Contract

Physician’s place of business. All procedures/tests will be performed during the initial visit with no return visits to be scheduled unless the Grissom Air Reserve Base (GARB) Civilian Personnel

XXXXXX

21 May 2014

Office (434 FSMC) designated representative (Designated Representative) requests further examination/testing. If the Contract Physician believes that follow-up medical exams and/or tests are required, the Contract Physician must provide a rationale before approval of any additional testing or follow-up visits will be granted. The Contract Physician will mail, fax, or send via electronic means (but will not provide to the applicant/employee) all medical exam results and documentation within 48 hours from completion of the examination in accordance with the Health Insurance Portability and Accountability Act (HIPPA). This includes laboratory, radiology or diagnostic tests and immunizations. The Contract Physician will become the agent of GARB and sign off on all medical documentation as the Medical Provider and the Agency

Medical Officer.

1.2 Non-personal Services: The services performed under this contract shall be non-personal services and are not inherently governmental. The prime contractor retains responsibility for any teaming partner or subcontractor and shall be accountable for their performance.

2. Definitions

Designated Representative: Any agency point of contact authorized to make appointments with the contractor. Those points of contact are:

Shari Matz

Ruth Tyson

Tammy Schlarf

Contract Physician: The prime contractor.

Contracting Officer: The person with authority to enter into, administer or terminate contracts, and make related determinations and findings on behalf of the Government. Note: The only individual who can legally bind the Government.

3. Purpose

A medical examination is appropriate only for a position which has specific medical standards, physical requirements or is covered by a medical evaluation program established by regulation.

Requests for fitness-for-duty, post-exposure, and termination physicals may require more extensive testing as specified on the Standard Form 78 or other designated forms. This program shall provide physicals for specific categories of applicants/employees. This program shall also provide pre-appointment, fitness-for-duty, post-exposure evaluations, termination, and overseas employment physicals. This is to determine if applicants/employees are medically qualified for, or continue to be medically qualified for, federal employment. Any questions concerning physical examination scope, to include scheduling, for the life of this contract shall be addressed through the Designated Representative to the Contracting Officer.

4. Services Required

The Contract Physician shall perform the following services listed below, all such services to be performed in accordance with all applicable standards and requirements, as provided to the

Contract Physician by the Designated Representative:

The Designated Representative will call the Contract Physician and schedule appointments in accordance with the statement of work and occupational medical requirements for each applicant/employee. Instructions will be provided to the Contract Physician by the Designated

Representative for individuals to receive the specified medical examination or required testing.

Any services above and beyond the basic requirements must be requested by the Contract

Physician for prior authorization and approval from the Designated Representative before continuing additional medical assessment, testing, examination or referrals. The Contract

Physician will provide to the Designated Representative any and all documentation evidencing the results of the assessment, testing, examination or referrals as required by the Designated

Representative.

4.1 Pre-employment examination: The Contract Physician will be provided the Standard

Form 78 (SF 78) (atch 1) and position description (PD) (atch 2) either by the individual to be examined or by facsimile or electronic transmission. The Contract Physician will review the checked items listed under “A – Functional Requirements” and “B – Environmental Factors” of the SF 78 and the physical requirements contained in the PD to ascertain if the individual is medically qualified for the position. The Contract Physician will complete Part C “To Be

Completed by Examining Physician,” sections 1-4, “Part D – to be Completed by Agency

Medical Officer” (Contract Physician), sections 104, and “Part F – Handicap Code” of the SF 78.

The completed form must be signed by the Contract Physician with appropriate recommendation(s) and returned to the Designated Representative within 48 hours from completion of the physical.

4.2 Periodic Examination: Tests and/or physical examination accomplished at intervals to evaluate return to duty after injury.

4.3 Fitness-for-Duty Examination: A fitness-for-duty examination may be required whenever there is a question about an employee’s continued capacity to meet the physical, mental or medical requirement of the position. A medical examination may be requested in any situation where additional medical documentation is needed to make an informed management decision.

The examination will be based on the SF 78 and PD, and any existing medical documentation from the employee’s personal civilian physician. The completed SF 78 must be signed by the

Contract Physician with appropriate recommendation(s) and returned to the Designated

Representative within 48 hours from completion of the physical examination.

4.4 Post-Exposure Exam: The Designated Representative will provide the medical requirements needed for each medical exam. If the Contract Physician deems further evaluation/medical testing is necessary, he/she is to contact the Designated Representative for approval prior to proceeding with further testing. Medical evaluation documentation is to include the Contract Physician’s written medical opinion of exposure, written physical exam, all radiological, laboratory testing and any other medical testing completed to make a determination of the exposure. These reports are to be provided to the Designated Representative within 48 hours from completion of the medical post exposure exam. In addition to the SF 78, the Contract

Physician must provide a previous workplace exposure history, SF 600 (atch 3).

4.5 Overseas Employment Physical: An overseas employment physical will be required whenever an applicant or employee has been selected for overseas employment. The Contract

Physician will be provided the SF 78 and PD either by the individual to be examined or by facsimile or electronic transmission. These documents will be used to conduct the examination in order to determine the individual’s fitness for employment in the oversea area. The Contract

Physician will review the job description and checked items listed under “A– Functional

Requirements” and “B – Environmental Factors” of the Standard Form 78 to ascertain if the individual is medically qualified. The Contract Physician will complete “Part C – to be completed by Examining Physician,” sections 1-4 and “Part – D to be completed by Agency

Medical Officer (Contractor),” sections 1-4 and “Part F – Handicap Code” of the Standard Form

78. The completed Standard Form 78 and supporting documentation must be signed by the

Contract Physician with appropriate recommendations and returned to the Designated

Representative within 48 hours from completion of the examination. In addition to the Standard

Form 78, the Contract Physician must provide a previous workplace exposure history, SF 600.

4.6 For Personnel Requiring the Use of Tight-Fitting Respirators: Contractor shall review both Initial and Annual Respirator Medical Evaluation Questionnaires (atch 4,5), as well as the

AF Form 2755 (atch 6) associated with the employee’s Industrial Workcenter, in order to evaluate, make appropriate recommendations based on findings, and indicate whether an employee is physically able to perform their work while wearing the prescribed respiratory protection. If additional testing is required, notify the Designated Representative.

5. Hours of Operation

All appointments will be scheduled/performed during the predetermined hours of operation developed by GARB and the Contract Physician on a recurring schedule. The schedule will be flexible to meet the needs of GARB. Business hours at GARB are Monday through Friday, 0730-1600 hours; except Federal Holidays. Requests for exceptions to this requirement will be coordinated with the Designated Representative.

6. Quality Assurance Evaluation (QAE)

434 SG will perform QAE surveillance over the work being provided by the Contract Physician within 30 days of the contract being executed and on an ongoing basis during the duration of the contract. All applicable regulations and guidance shall be provided to the Contract Physician by the QAE so that the Contract Physician may comply with the requirements thereof.

7. Contractor Requirements

The Contract Physician is responsible for providing his/her own facility and all machines and equipment to conduct physical/medical exams and testing.

8. Location

All work to be performed will take place at the Contract Physician’s offices. The contract vendor’s business location must be within the boundary area from Grissom ARB to South Bend, IN, Fort Wayne, IN, Lafayette, IN, and Indianapolis, IN.

9. Government Points of Contact

Shari Matz – 765.6884840

Ruth Tyson – 765.688.4839 Tammy Schlarf – 765.688.4836

10. Attachments

1. Certificate of Medical Examination – Standard Form 78

2. Position Description (PD)

3. Chronological Record of Medical Care – Standard Form 600

4. Initial Respirator Medical Evaluation Questionnaire

5. Annual Respirator Medical Evaluation Questionnaire

6. Master Workplace Exposure Data Summary – AF-2755

Projected number of exams on a yearly basis:

Pre-employment 5

Periodic 15-25

Fitness for duty 6

Post-exposure 1

Overseas employment 1

Termination 2

Courtesy 5

(End of Summary of Changes)