GRISSOM_PWS_FOR_FA4654-14-B-0001_3_MAR_2014.pdf

March 3, 2014 Grissom Air Reserve Base, IN 46971

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

MARCH 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, occupational and occupational annual exams, post-exposure evaluations, employment termination physicals, overseas employment physicals, and vision and hearing exams 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.

Audiograms must be performed by a technician certified by the Council for Accreditation and

Occupational Hearing Conservation (CAOHC). Testing for illegal drugs will not be done as part of annual medical evaluations. Additionally, the Contract Physician’s facility must have the capability to perform examinations for Firefighters and Police Officers, to include but not limited to pre-employment, occupational health and fitness-for-duty examinations in accordance with prescribed regulations and certification requirements. 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 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, audiometric, 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, occupational and occupational annual exams, 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 to include Firefighters and Police Officers. This program shall also provide pre-appointment, fitness-for-duty, occupational and occupational annual exams, 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 Physical Requirements for Annual Occupational Exam: The Designated Representative will provide the medical requirements needed for each occupational medical exam via information provided on the AF Form 2755, Master Workplace Exposure Data Summary (atch

3), and the required tests as identified on the AF Form 2766, Clinical Occupational Health

Examination Requirements (atch 4). One of each of these forms will be provided to the contractor for each Industrial Workcenter whose personnel require occupational physical examinations. The medical reports and supporting documentation will be provided to the

Designated Representative within 48 hours from completion of the annual examination. Results of the annual exam are to be filed in the employee’s civilian medical records file. In addition to the SF 78, the Contract Physician must provide a previous workplace exposure history, SF 600

(atch 5).

4.5 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.

4.6 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.

4.7. For Firefighters: All examinations must be conducted in accordance with National Fire

Protection Association Codes (NFPA), Technical Implementation Guide (TIG) 1582 (atch 6), Occupational Safety and Health Administration (OSHA) 29 CFR § 1910, DoD 6055.05-M, and

Air Force Standards.

The Contract Physician will perform examinations as part of the National Fire Protection

Association (NFPA) 1582, Standard on Comprehensive Occupational Medical Program for Fire

Departments.

4.8 For Police Officers: All examinations and testing will be conducted in accordance with the requirements of Air Force Instruction 31-122, Department of the Air Force Civilian

Police/Security Guard (DAF CP/SG) Program, and with all applicable regulations, laws and standards set forth therein. These examinations will include, but not be limited to, pre-employment exams, fitness-for-duty exams, periodic occupational health and injury compensation examinations, and medical clearance for the Physical Agility Testing (PAT) (atch

7).

4.9 For Personnel Requiring the Use of Tight-Fitting Respirators: Contractor shall review both Initial and Annual Respirator Medical Evaluation Questionnaires (atch 8, 9), as well as the

AF Form 2755 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 – Provided Post Award

Ruth Tyson –

Tammy Schlarf –

10. Attachments

1. Certificate of Medical Examination – Standard Form 78

2. Position Description (PD)

3. Master Workplace Exposure Data Summary – AF-2755

4. Clinical Occupational Health Examination Requirements – AF-2766

5. Chronological Record of Medical Care – Standard Form 600

6. Technical Implementation Guide (TIG)

7. AFI 31-122, Air Force Civilian Police/Security Guard (DAF CP/SG) Program, and Medical

Clearance for Physical

8. Initial Respirator Medical Evaluation Questionnaire

9. Annual Respirator Medical Evaluation Questionnaire

Projected number of exams on a yearly basis:

Pre-employment 5

Periodic 15-25

Fitness for duty 6

Annual

Firefighters 50-60

Police officers 18-20

PAT 18-20

Post-exposure 1

Overseas employment 1

Termination 2

Courtesy 5