PWS_Pain_Management_Nurse.docx

PERFORMANCE WORK STATEMENT

FOR

PAIN MANAGEMENT REGISTERED NURSE

AT

RAF LAKENHEATH, UNITED KINGDOM

Page 2 of 22 Pages

Table of Contents

Section Number and Title

Page Number

3.0 Government Furnished Property and Services

8.0 Appendices

Appendix A, Standards Appendix B, Worksheets Appendix C, Maps/Blueprints Appendix D, Required Reports/Forms Contract Bid Schedule

PERFORMANCE WORK STATEMENT

Pain Management Registered Nurse (Clinical/Conscious Sedation Nurse)

Non-Personal Services

1.0 Description of Services. The Government requires one (1) Full Time Equivalent (FTE) Pain Management Registered Nurse for this contract at the established facilities at the 48th Medical Group, RAF Lakenheath, England, also referred to as the “Medical Treatment Facility” (MTF) herein. Performance shall be in accordance with the requirements contained in this Performance Work Statement (PWS), and standards of the Joint Commission and Health Services Inspection (HSI).

1.1 This position shall serve as a Registered Nurse providing support for the 48 Medical Groups Pain management clinic. Duties inlclude, but not limited to nursing care, monitoring of plans and equipment, response to medical emergencies, conduct pre/post operative visits, provide service for military exercises of contingency plans and emergency situations. If the vendor is a US military dependant, please disclose DEROS information. Additionally, prospective vendors shall provide pricing only on those option CLINs in which they will be available to perform in their entirety or specify their availability within the performance period of any CLIN if not available for the entire year.

2.0 Service Summary.

2.1 If contractor fails to perform IAW the PWS the QAP/COR shall complete a Corrective Action Report (CAR) and submit it to the Contracting Office. This form is used to document a contractor’s failure to meet critical Service Summary requirements, but may be used for other contract related infractions. It is encouraged to resolve minor infractions at the lowest level possible, but ensuring the Contracting Office is in the chain. At no time may a contractor be instructed not to contact the Contracting Office. This is a non-personal service and the contractor’s recourse is always with the Contracting Office.

2.2 SERVICE SUMMARY

6.4

6.28, 6.29

the spot to have zero impact on patient care

5.7.4.4 -5.7.4.8, 6.16

3.0 Government Furnished Property and Services. Contractor shall be provided Government-controlled working space, material, equipment, services (including automatic data processing), or other support which the Government determines can be made available at RAF Lakenheath where this contract shall be performed.

4.0 Contractor-Furnished Items and Services. Contractor is not required to provide or furnish any items or property.

5.0 GENERAL CONTRACTOR REQUIREMENTS AND RESPONSIBILITIES

5.1 HOURS OF WORK. The contractor employee(s) work schedule will be determined by the flight commander based on the needs of the clinic or floor in which the contractor employee(s) is to provide the service. The contractor employee(s) may be required to work more than 8 hrs in a single day or 40 hours in a week and holidays. All hours in excess of 40 hours, weekend or night shift hours will be paid at the same hourly rate as regular hours of work. If additional hours are worked, the Government may reduce future scheduled hours to maintain a 40 hour work week average. All hours worked will be recorded accurately on the work schedules. Under no circumstances are the work schedules to reflect hours worked when the contractor employee(s) was absent or vice versa.

5.1.1 On occasion, services may be required to support an activation or exercise of contingency plans outside the normal duty hours for a crisis declared by the national command authority or overseas combatant commander. Emergency situations (i.e., accident and rescue operations, civil disturbances, natural disasters, military contingency operations, and exercises) may necessitate the contractor employee(s) provide increased or reduced support as determined by the contracting officer. If necessary, the Government will negotiate an equitable adjustment for the cost of these emergency requirements.

5.1.2 As directed by the MTF, will be required to attend Government provided additional training in patient care aspects and procedures.

5.2 INDIVIDUAL LOGISTICAL SUPPORT. Individual logistical support may be provided under this contract in accordance with FAR 25.802, DFARS 225.802, and the policies and procedures of DoD 4525.6-M and AFI 36-3026. Policies and procedures are subject to change. Examples of support may include: DOD Common Access Card (CAC); Commissary (including rationed items); Base Exchange (including rationed items); MWR Facilities (e.g. chapels, clubs, cinema, fitness center); Military Banking Facilities; Military Postal Service (APO/FPO); Mortuary Services (on reimbursable basis); POV (Privately-Owned Vehicle license); Purchase of POL (Petroleum and Oil products); Transient Billets or Visiting Officers Quarters (VOQ) on space-available and reimbursable basis when travel is performed on Official Government Orders; Department of Defense Dependent Schools (DODDS) on a space guaranteed and tuition paying basis; Medical services on a reimbursable basis; Dental care only for emergency conditions on a reimbursable basis; Pet/Firearm Registration and Control and Housing Referral.

5.2.1 Logistical support is not authorized for non-US vendors or non-US national employees of US vendors pursuant to the concession agreement with Her Majesty’s Revenue and Customs (HMRC). Local National hires may be authorized a CAC if their duties require access to Government computer programs.

5.3 ABSENCE. Scheduled absences (i.e. leave or holidays) are to be coordinated a minimum of 2 weeks in advance. Notify the Flight Commander or designee as early as possible of unscheduled absences to allow for planning of service coverage and workload distribution.

5.3.1 The MTF will notify contract personnel in advance of upcoming down days to the greatest extent possible for scheduling purposes. In the event of unplanned closure of the facility due to natural disasters, military emergency, or severe weather, contract employees will not perform duties and the Government will not be charged billable hours.

5.3.2 The contractor is required to provide temporary replacement staff for Contractor personnel absences, scheduled or unscheduled, of more than or equal to 30 calendar days.

5.4 DRESS AND APPEARANCE. Contractor employee(s) shall present a professional, conservative, and neat appearance. Contractor employee(s) shall report for duty in a professional manner, in appropriate attire befitting a health care setting, and having complied with socially acceptable standards of personal hygiene expected of health care workers.

5.4.1 While on duty, Contractor personnel shall be neat and clean (free from visible dirt and stains), well groomed and appropriately dressed. The personnel’s clothing shall fit correctly to provide a professional, modest appearance, in keeping with normally accepted community standards of dress for the work being performed.

5.4.2 Contractor personnel shall display legible MTF-provided identification media on their outer clothing.

5.4.3 Facial hair (including beards, mustaches, and sideburns) shall be controlled (restrained) or trimmed. It shall not interfere with safe work practices, look unkempt, or be unclean.

5.4.4 When required and supplied by the Government, wear special protective clothing and shoe covers. When duties will be performed in specified areas, a disposable protective hood shall be worn to ensure infection control standards are met. These items shall remain the property of the Government and shall not be removed from the MTF. After use, protective clothing shall be turned in or destroyed as directed by the Chief of Service.

5.5 OFFICE SKILLS. RN shall possess working knowledge of computers, computer programs specific to this medical group, specifically the Internet, Microsoft Word, Microsoft Access, Microsoft Excel, and Windows

5.6 SECURITY.

5.6.1 See Appendix 1 for information regarding Host Agency Checks (HAC) and National Agency Checks (NAC).

5.6.2 During performance, report any information or circumstances observed that may pose a threat to the security of DoD personnel, contractor personnel, resources, and defense information to the Security Forces. The Flight Commander will brief the contractor employee(s) upon initial on-base assignment and as required thereafter. Comply with the requirements of Volume 1, AFI 71-101, Criminal Investigations, and paragraph 1.1 of Volume 2, Protective Service Matters.

5.6.3 Adhere to local base procedures for entry to Air Force controlled/restricted areas.

5.6.4 Ensure keys issued by the government are properly safeguarded and not used by unauthorized personnel. Do not duplicate keys issued by the government.

5.6.5 Lost keys shall be reported immediately to the facility manager. The government replaces lost keys or performs re-keying.

5.7 Healthcare Requirements.

5.7.1 In accordance with Federal Acquisition Regulation 37.401 with regard to Non-Personal Services for health care services, the following information is provided:

5.7.1.1 This is a NON-PERSONAL health care services contract, as defined in FAR 37.101, under which contractor employee(s) are provided by an independent contractor.

5.7.1.2 The Government may evaluate the quality of professional and administrative services provided, but retains no control over the medical, professional aspects of services rendered (e.g., professional judgments, diagnosis, for specific medical treatment).

5.7.1.3 The contractor hereby indemnifies the Government for any liability producing act or omission by the contractor, its employees and agents occurring during contract performance.

5.7.1.4 The contractor/ contractor employee(s) shall maintain medical liability insurance.

5.7.2 Contractor employee(s) must comply with 48th Medical Group and unit standards of care as well as the healthcare practices of their specific profession. See Appendix 2 for a list of applicable publications and forms; this list is not exhaustive.

5.7.2.1 Recognize adverse signs and symptoms and react quickly in emergency situations.

5.7.2.2 Provide patients with the utmost care and undivided attention.

5.7.2.3 Ensure a safe work environment and employee safe work habits.

5.7.2.4 Participate in Quality Inspection and Risk Management activities to the extent that falls within the scope of this PWS.

5.7.3 HIPAA. All patients shall be assured of their privacy and personal dignity. Follow guidelines for confidentiality and privacy based on the Health Insurance Portability and Accountability Act (HIPAA). See Appendix 3 for more information.

5.7.4 RELEASE OF INFORMATION AND RECORDS MANAGEMENT.

5.7.4.1 Only release medical information obtained during the course of this contract to MTF staff involved in the care and treatment of that individual patient.

5.7.4.2 Lists and/or names of patients shall not be disclosed or revealed in any way for any use outside the MTF without prior written permission by the Chief of Hospital Services.

5.7.4.3 Refer all other requests for records to the Outpatient records center.

5.7.4.4 Prepare all documentation/records to meet or exceed established standards of the MTF, to include, but not limited to, timeliness, accuracy, content and signature. Only MTF and Air Force-approved abbreviations shall be used for documentation of the patient health record. For unapproved abbreviation list see MDGI 44-116, attch 2 and 3.

5.7.4.5 Generate and manage IAW DoD 5400-7R, DoD Freedom of Information Act Program, Chapter 4; AFI 33-129, Web Management and Internet Use, paragraphs 7.4, 8.2.3, 16 and 17; and AFI 33-201, Communications Security (COMSEC), Table 1.

5.7.4.6 Mark IAW instructions identified in DoD 5400-7R paragraph C4.2.1. Safeguard all sensitive data IAW DoD Regulation 5400.7/Air Force Supplement, paragraph C4.4.

5.7.4.7 When authorized for destruction, shred the records so that the pieces cannot be reconstructed. Degauss or overwrite magnetic tapes or other magnetic media.

5.7.4.8 Patient lists, no matter how developed are FOUO and shall be marked: “FOR OFFICIAL USE ONLY. This document contains information exempt from mandatory disclosure under the Freedom of Information Act (FOIA), Title 5 U.S.C. 552(b)(2) High and (b)(6) apply.”

5.7.5 CREDENTIAL MAINTENANCE.

5.7.5.1 RN shall have and provide a current certification in Pediatric Advanced Life Support (PALS), Basic Life Support (BLS) and Advanced Cardiac Life Support (ACLS) by the American Heart Association. RN shall have and maintain an active, valid unrestricted, current nursing license (with no limitations, stipulations or pending adverse actions). All licenses must be unencumbered and remain in effect during contract employment. The RN shall be in good standing, and under no clinical restrictions, with the state licensure board in any state in which a license is held or has been held within the last 10 years.

5.7.5.2 The RN shall be current with and have completed all continuing education requirements specified by their US professional licensure or certification.

5.7.5.3 An annual physical examination is required. The contractor employee(s) must provide proof of the medical examination by a qualified medical practitioner and required immunizations prescribed by the MTF for continued employment within the facility. Report all information necessary to assure hospital records can be maintained correctly, and therefore comply with the Joint Commission, Operational Safety and Health Administration (OSHA), and Center for Disease Control (CDC) health record requirements.

5.7.6.4 Reserved.

5.8 Position Qualification Requirements.

5.8.1 Education: Registered Nurse (RN) must have achieved at minimum an Associate Degree in Nursing (ADN) or Diploma Degree in Nursing. Offeror must have graduated from a Nationally Accredited Nursing Program or an US recognized UK nursing program equivalent that is acceptable to the USAF Surgeon General.

5.8.2 Experience: RN shall have 12 months of Pain Management or comparable clinical experience within the last 36 months. Experience must include all phases of clinical technique such as preparing procedure room units, preparing patients for clinical procedures, and assisting medical officer during procedures. To include, conscious sedation experience and intensive treatment experience, with the ability or willingness to learn IT systems required to deliver an effective service. Manage the referral, admission and discharge of patients from own caseload.

5.8.3 Certifications: Public Health clearance is required and contractor employee(s) shall submit immunization records and physical health certification with their proposal. The records must show proof of immunization against Hepatitis A and B, Measles, Mumps, Rubella, Varicella, and Influenza. The offeror shall also provide proof of negative TB skin test taken within the past 12 months. If the TB test was positive, submit proof of negative chest x-ray within the past 12 months. After start of work, the government will provide post bloodborne exposure protocols according to applicable AFIs. The health certification shall state the date on which the physical examination was completed, the name of the doctor who performed the examination, and a statement concerning the physical health of the individual. The certification shall also contain the following statement: “(Name of contractor personnel) is suffering from no contagious diseases to include, but not limited to, Tuberculosis, Hepatitis A and B and HIV.”

5.8.4 Medical Liability Insurance: Medical insurance is required for this position and proof of insurability will be provided with solicitation proposal. Evidence of Liability insurance coverage will be submitted to the Contracting officer and COR prior to contract performance.

5.9 Bioenvironmental Engineering/Hazmat Requirements

5.9.1 Environmental, Health, And Safety. The contractor shall ensure all employees receive the necessary environmental, health, and safety training to ensure compliance with all Occupational Safety and Health Acts (OSHA), federal and local laws. The contractor shall protect the health and safety of employees and the community, minimizing the risk of environmental pollution.

5.9.2 Pollution Prevention. “Pollution Prevention” and “Source Reduction” are defined in the Pollution Prevention Act of 1990, 42 U.S.C. §§ 13101-13109. Contractor’s obligation under this section is limited to identifying pollution prevention opportunities and shall not be construed to require the contractor to conduct activities not otherwise required by the program.

5.9.3 The contractor’s employee(s) shall comply with energy saving conservation practices as deemed necessary by the facility manager.

5.9.4 Ionizing and Non-Ionizing Radiation: Contractors must obtain authorization from BE prior to bringing on site ionizing or non-ionizing sources/equipment onto the installation. Contractors must provide list of items and description of how they will be used to Bioenvironmental Engineering (BE) at 01638528047 or 48amds.sgpb@us.af.mil at least 10 days prior to the date required to bring them on base.

5.9.4.1 Non-Ionizing Radiation: Electromagnetic Frequency (EMF) Radiation and LASERS: Contact BE/Installation Laser Safety Officer (48amds.sgpb@us.af.mil) at least 10 days prior to bringing on site. (Example: LASER Classes: 1M, 2M, 3R, 3B, or 4; Transmitting antennas, radars etc.) Reference: AFI 48-139, LASER and Optical Radiation Protection Program, Paragraph 2.21)

5.9.4.2 Ionizing sources: Contact BE (48amds.sgpb@us.af.mil) at least 10 days prior to bringing on site ionizing sources/equipment. For regulated sources, provide copies of permits or sealed source certifications. (Example: Troxler density gauges, sealed sources in various gauges/devices). Reference: AFI 48 -148, Ionizing Radiation Protection.

5.9.5 Hazardous Materials/Chemical Management: Hazardous Materials/Chemical Management: All hazardous material use requires prior authorization before bringing the hazardous material on base. “Hazardous material” includes many materials for which there is a manufacturer SDS, such as cleaning supplies, paints, solvents, sealants, lead acid batteries, fuels, herbicides, etc.

5.9.5.1 The Contractor shall submit an inventory list of ALL chemical products to be used, along with copies of the Safety Data Sheet (SDS) for each chemical product, for review before bringing any potentially hazardous material onto RAF Lakenheath, RAF Feltwell or RAF Mildenhall using the attached “HazMat Authorization Request Template”. The Contractor shall submit completed inventories and SDSs to the 1) CO, 2) CE Environmental / for RAF Lakenheath (01638 523990) (nolan.swick@us.af.mil), or for RAF Mildenhall 100 CES/CEIE (01638 545831), jeanne.dye-porto@us.af.mil and 3) Bioenvironmental Engineering (01638 528047) (48amds.sgpb@us.af.mil) at least 10 days prior to the date required to bring them on base.

5.9.5.2 Once approved, the Contractor must maintain an inventory of all hazardous materials along with corresponding Safety Data Sheets (SDSs). The Contractor shall track and report actual hazardous material usage during the performance of the contract. Hazardous material usage for any contract that is less than one month in duration will be reported at the end of the contract period. Hazardous material usage for any contract over a month in duration will be reported no less than monthly. Hazardous material usage will be reported using the attached “HazMat Monthly Usage Log Template”.

5.9.5.3 The Contractor shall not leave any excess hazardous materials or empty containers on site following completion of the project. The Contractor is responsible for the removal of all unused hazardous materials and proper disposal of all hazardous waste generated. Reference: AFI-32-7086, Hazardous Materials Management

5.9.6 Controls of other hazards: Contractors must coordinate with Bioenvironmental Engineering (BE) at 01638528047 or 48amds.sgpb@us.af.mil at least 10 days prior to start of project, regarding all contracts with potential health impact to personnel (Example: Noise above 85 dBA, activities with potential airborne contaminants or particulates). Hazardous work areas/perimeters shall be established to control exposures and limit access to nearby facilities and personnel. Work shall be performed IAW all applicable occupational health and safety regulations.

5.9.7 Contractors must coordinate with facility managers and receive a safety brief of hazards present within work areas.

5.9.8 Uses and Safeguarding of Information: Information from the secure web site is considered to be proprietary in nature when the contract number and contractor identity are associated with the direct labor hours and direct labor dollars. At no time will any data be released to the public with the contractor name and contract number associated with the data. Contractors for other than Army components can visit https://cmra.army.millLogin.aspx to review user manuals and gain an understanding about the data fields that will be included in the reporting structure that is hosted at http://www.ecmra.mil/ Applicability: The reporting requirement applies to all contracted services, provided the organization that is receiving or benefiting from the contracted services is a Department of Defense organization, including reimbursable appropriated funding sources from non-DoD executive agencies where the Defense Component requiring activity is executive agent for the function performed. The reporting requirement does not apply to situations where a Defense Component is merely a contracting agent for another executive agency. In general, the only contracted services excluded from reporting are construction and utilities.

6.0 SPECIFIC TASKS.

6.1 The contractor employee(s) shall perform or shall know how to perform the tasks listed below. The contractor employee(s) shall at no point receive additional payment for performing tasks outside of this list or outside of the scope of this contract. If additional tasks are required, the contractor and customer shall contact the contracting officer prior to performance in order to increase the scope of the contract and complete negotiations for equitable adjustment.

6.2 The RN’s primary role will be to provide nursing care for patients in the Pain Management Clinic. These roles include but are not limited to assisting the pain physician with procedures, conscious sedation, recovery of a sedated patient, telehealth, perioperative screenings, nursing assessment, managing pain clinic template, managing pain equipment and supplies.

6.3 The Nurse shall plan, direct and coordinate activities of the pain management clinic.

6.4 Provides professional nursing care to patients undergoing procedures.

6.5 Establishes and utilizes a checklist to monitor the physical plan of the Pain Management Clinic and equipment for conformity to all national standards for ensuring safety for the patient and all personnel.

6.6 Assembles the type and quantity of material and special equipment needed for daily procedures and possible emergencies.

6.7 Circulates for procedures.

6.8 Responds to surgical emergency requirements such as cardiac, pulmonary or respiratory failure and hemorrhage.

6.9 Maintains open communication lines, both intra-departmentally and interdepartmentally, to provide for total needs of the patient.

6.10 Conducts preoperative and postoperative visits.

6.11 Discusses operative procedures with patients and informs them of what to expect during procedures.

6.12 Consults with the anesthesiologist and establishes priorities of care for each patient entering the clinic and operating suite.

6.13 Coordinates with other hospital units, which include recovery room, intensive care, obstetrics, and nursing units, on patients progress and any special equipment or supplies that will be needed for the patient returning from surgery.

6.14 Participates in preparing, sterilizing and caring for pain management procedure equipment and supplies.

6.15 Adheres to central sterile supply service activities.

6.16 Maintains concise and complete records and reports.

6.17 Coordinates an ongoing, in-service, education program to continuously update knowledge and skills of all assigned nursing personnel.

6.18 Pain Management RN is to provide care based upon the assessed needs of the patient in relation to the proposed procedure. The duties required by the Pain Management RN positions are as follows, but not limited to:

6.19 Provides pain management nursing care, for all types of patients admitted to the conscious sedation clinic for interventions. Includes elective, urgent and emergency procedures on patients of all ages.

6.20 Assesses, plans, implements and evaluates nursing care for all patients including newborns, children, adolescents, adults and the elderly; disabled to include visually and hearing impaired; and individuals of varying ethnic and religious backgrounds to include those who do not speak or understand English.

6.21 Accurately completes documentation of patient care events and process improvement activities IAW MTF guidelines.

6.22 Participation and compliance with quantity and process improvement activities and events to ensure compliance with national standards and guidelines.

6.23 Knowledge of a variety of pharmacological agents used in patient treatment, the desired effects, side effects, and complications of their use as well as the accurate administration of the pharmacological agent, including dosage calculations required.

6.24 Displays knowledge of the administrative requirements for proper documentation of patient’s condition including disease progress, acknowledgement of teaching and follow up care.

6.25 Displays knowledge of laboratory test values.

6.26 Administers medications, electrolytes, fluids, blood and blood products.

6.27 Adheres to perioperative, infection control and safety policies and procedures.

6.28 Safely operate and monitor specialized therapeutic and resuscitative equipment.

6.29 Skilled in setting up, operating and monitoring specialized medical equipment such as IV infusion pumps, cardiac monitoring devices, EKG units, oxygen analyzers, nebulizers and other unit specific equipment.

6.30 Exhibits excellent patient assessment skills.

6.31 Effectively communicates and collaborates with a diverse group of people for the purpose of informing the healthcare team of plans/actions, for teaching/education to benefit the patients/family and organization.

6.32 Effectively uses appropriate communication format in addressing professional issues.

6.33 Displays excellent written communication skills to perform accurate documentation, both written and electronic, of all activity in accordance with requirements.

6.34 Coordinates patient care through a continuum and facilitates the achievement of optimal outcomes in relation to care, quality and cost effectiveness.

6.35 Ensures compliance with standards of care and practice in accordance with all established policies, procedures and guidelines used in the medical treatments facility, Provides care within ethical and legal boundaries.

6.36 Recognizes medical emergencies and responds appropriately. Initiates CPR if required. Assists surgical team in administering advanced cardiac life support measures when necessary.

7.3 Official Foreign Exchange

7.3.1 Foreign currency rates shall be obtained from the Under Secretary of Defense (Comptroller) website. The foreign currency rates information can be obtained via the web at the below address.

http://comptroller.defense.gov/FinancialManagement/Reports/fcfr.aspx

8.0 APPENDICES

APPENDIX 1

NATIONAL AGENCY CHECK (NAC)/HOST AGENCY CHECK (HAC). The government will submit an investigation request for the awardee on AF Form 2583, “Request for Personnel Security Action”, at no additional cost to the contractor. The contractor employee(s) must successfully pass a National Agency Check (NAC) US or Host Agency Check (HAC) UK to be eligible for contract award. Any contractor receiving an unfavorable NAC/HAC shall be Terminated for the Default.

UNESCORTED ENTRY - CAC:

1. Those personnel requiring CAC cards are issued one because they are either authorized Logistical Support (i.e. Commissary, BX, Gas Station) and/or computer access. US personnel shall have a NAC initiated by the gaining units Security Manager or for UK personnel the gaining units HAC POC. It is the Trusted Agents (TA) responsibility to ensure these checks are initiated.

2. The contract award document contains the information whether or not an individual is authorized Logistical Support or requires computer access in performance of their job. This has to be verified by the contractors TA.

3. TA’s are individuals assigned by their unit to “sponsor” contractors in Contractor Verification System (CVS) allowing them to be issued a CAC. The TA will initially load the contractor in CVS which prompts the contractor to go into CVS and verify the information. The TA will provide instructions on how this is accomplished.

4. DD Form 1172-2, Application for Department of Defense Common Access Card DEERS Enrollment, must be completed and submitted with the DD Form 557, Appointment/Termination Record- Authorized Signature. The TA must fill out the DD Form 1172-2, all typed, if there is any hand written information on the form (other than signatures) the MPF office will reject the form. The TA must fill in Section I, Employee Information; Section II, Employee Declaration and Remarks, here is where the contractor’s security clearance information (NAC or HAC) goes and all authorized Logistical Support, the contractor signs and dates boxes 37 and 38; and Section III, Authorized/Verified By, is where the TA fills in their information. They verify the contractors’ signature in Section II and then the TA signs Section III. The DD Form 577, Appointment/Termination Record- Authorized Signature, and as the name implies, verifies the TA’s name and signature. This is used to compare the name and signature in Section III of the DD Form 1172-2. MPF will not accept the DD Form 1172-2 or process the contractor in DEERS without a DD Form 577 indicating the TA.

5. Occasionally, a contractor may arrive at RAF Lakenheath assigned to a TA from another base, this is not a problem. In this instance the contractor must ensure they bring with them the completed and signed DD Form 1172-2 and a copy of the TA’s DD Form 577.

6. If the contractor has dependents accompanying them the DD Form 1172, Application for Uniformed Services Identification Card/DEERS Enrollment, may be required. The completed form is required if the dependents have never been issued a DoD identification card. The TA is required to fill out and sign the DD Form 1172 and the form must accompany the contractor. If the dependents have a current card then the DD Form 1172 is not required to accompany the contractor as MPF will be able to pull the DD Form 1172 off of the system since the individuals will already be in DEERS. IMPORTANT: Contractors must report to MPF with their passport and Social Security Card and those of their family members as well.

7. The ORIGINAL DD Form 1172-2 and DD Form 1172 must accompany the contractor. This is per the Status of Forces Agreement (SOFA); the original is required because MPF must send it to DMDC. If the contractor is assigned a TA from RAF Lakenheath the same information is required.

8. If the contractor employee(s) is a local national they must first complete the steps listed below for a HAC. Once the HAC is complete the contractor employee(s) must go to MPF and get assigned a Foreign Identification Number (FIN); the contractor will need to coordinate with their TA and MPF. The TA needs the FIN to load the contractor into CVS and it is also required on the DD Form 1172-2. The contractor employee(s) shall take the completed form to MPF and they will input the DD Form 1172-2 into DEERS and issue the CAC.

9. The contractor employee(s) shall take all of the required forms and documents to MPF on the ground floor of Bldg 977 and proceed with CAC/ID issuance.

HAC – Host Agency Check:

1. The Ministry of Defence (MoD), Defence Vetting Agency, conducts HAC checks on individuals who are UK nationals, US citizens without componency status (i.e. a retiree who chooses to stay in the UK) or third country nationals (TCN). If a person falls under one these categories they must reside within the UK for 4 years before a HAC will even be accomplished.

2. These individuals will be assigned a HAC POC by their gaining unit. The POC will initiate the MOD Form 1109, Host Agency Check, please keep in mind that this check can take 4 – 6 months to accomplish and is good for 5 years. In conjunction with the MOD Form 1109 the contractor employee(s) will be required to complete a BCVR, Base Check Verification Record form; the AF Form 2583, Request for Personnel Security Action; and a USAFE Form 19, Residency Check.

3. After return of the security check the following will occur: the gaining units HAC POC will complete the USAFE Form 79 and submit a package with all completed forms to the HAC office for review. If there are mistakes the package is returned for correction and then resubmitted. Once a proper package is completed the HAC POC will give the contractor employee(s) all required forms to bring to Pass and ID, in Building 977; the number is 01638 52 5990 or DSN 226-5990. Pass and ID will then issue the contractor employee(s) either a USAFE Form 77, Base Pass, which is good for 365 days or a CAC depending on their required contractual duties.

ESCORTED ENTRY:

1. Contractor personnel requiring escorted entry on to RAF Lakenheath shall provide the first name and surnames of all personnel requiring entry. Provide a list of the vehicles that will be entering the installation to include: make, model and registration number. Also, the Road Tax disc must be current. Also include the award number, location of work and start/stop dates. This shall be on company letterhead and can be either mailed or sent electronically. Bear in mind that regardless of the submittal process the contracting office must have the paperwork five days prior to start of work.

2. This information is then submitted to the requesting activity and they in turn provide the information to the Security Forces Operations branch.

NOTE: All contractor employee(s) must arrive at the installation with a picture ID (i.e. passport or drivers license), if they are not in possession of a picture ID they will not be allowed entry.

APPENDIX 2

APPLICABLE PUBLICATIONS AND FORMS

Publications and forms applicable to this Performance Work Statement (PWS) are listed below. The contractor shall follow those publications to the extent (that is, the specific procedure in a paragraph, section, chapter or volume) specified in the PWS. The Government provides all publications and forms listed, they are provided electronically at http://www.e-publishing.af.mil/. The Government may issue supplements or amendments to listed publications from any organizational level during the life of the contract. It is the contractor’s responsibilities to check the website for updated supplements. The contractor shall immediately implement those changes in publications that result in a decrease or no change in the contract price. Before implementing any such revision, supplement, or amendment that will result in an increase in contract price, the contractor shall submit to the contracting officer (CO) a price proposal for approval. Price proposals shall be submitted within 30 calendar days from the revision, supplement, or amendment giving rise to the increase in cost of performance. The Government will consider changes in the contract price due to supplements and amendments shall be considered under the "Contract Terms and Conditions-Commercial Items" clause. The Government will continue to supply the Government forms needed for daily operations.

Publications Code:

MDGI - Medical Group Instruction

DEPARTMENT OF DEFENSE (DOD) REGULATIONS/MANUALS/INSTRUCTIONS/DIRECTIVES

Number Title of Directive Date

Contractor Services During a Crisis

AIR FORCE REGULATIONS/MANUALS/INSTRUCTIONS

Number Title of Directive Date

AIR FORCE REGULATIONS/MANUALS/INSTRUCTIONS

AFI 44-119 Clinical Performance Improvement Jun 01

Publications are available electronically. DoD publications are available at http://west.dtic.mil/whs/directives/ and AF publications are available at http://www.e-publishing.af.mil/.

APPENDIX 3

HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA) OF 1996

HIPAA is comprised of several different sections, each to be implemented by the Dept. of Health and Human Services. The medical facilities of the military services and the DOD health plans are specifically listed as covered by HIPAA. Currently, HIPAA Privacy and Security Rules, as set forth in the Code of Federal Regulations, are in effect for all MTFs. The specific implementation of HIPAA Privacy for DOD medical facilities is set forth in DOD 6025.18-R, and for HIPAA Security, the requirements for AF MTFs are contained in DOD 8580.02-R and AFI 41-217, which also contains additional Information Assurance requirements for all AF MTFs. DOD 6025.18-R, DOD 8580.02-R and AFI 41-217 are incorporated herein by reference. MTFs are responsible to insure overall compliance with HIPAA requirements, which includes incorporation of certain requirements in contracts entered or amended after the respective implementation dates.

IAW these regulations, the Contractor and its employees meet the definition of Business Associates. Therefore, a Business Associate Agreement is required by law to comply with both the HIPAA Privacy and Security regulations. This clause serves as that agreement for each MTF, whereby the Contractor and its employees agree to abide by all HIPAA Privacy and Security requirements regarding health information as defined in this clause, DoD 6025-18-R, DOD 8520.02-R and AFI 41-217. Additional HIPAA requirements will be addressed when implemented.

Introduction

(a) Definitions. As used in this clause generally refer to the Code of Federal Regulations (CFR) definition unless a more specific provision exists in DOD 6025.18-R, DOD 8520.02-R or AFI 41-217.

Individual has the same meaning as the term “individual” in 45 CFR 164.50 1 and 164.103 and shall include a person who qualifies as a personal representative in accordance with 45 CFR 164.502(g).

Privacy Rule means the Standards for Privacy of Individually Identifiable Health Information at 45 CFR part 160 and part 164, subparts A and E.

Protected Health Information has the same meaning as the term “protected health information” in 45 CFR 164.501, limited to the information created or received by The Contractor from or on behalf of the Government.

Electronic Protected Health Information has the same meaning as the term “electronic protected health information” in 45 CFR 160.103.

Required by Law has the same meaning as the term “required by law” in 45 CFR 164.501 and 164.103.

Secretary means the Secretary of the Department of Health and Human Services or his/her designee.

Security Rule means the Health Insurance Reform: Security Standards at 45 CFR part 160,162 and part 164, subpart C.

Terms used, but not otherwise defined, in this Agreement shall have the same meaning as those terms in 45 CFR 160.103, 160.502, 164.103, 164.304 and 164.501.

(b) The Contractor agrees to not use or further disclose Protected Health Information other than as permitted or required by the Contract or as Required by Law.

c) The Contractor agrees to use appropriate safeguards to prevent use or disclosure of the Protected Health Information other than as provided for by this Contract.

(d) The Contractor agrees to use administrative, physical, and technical safeguards that reasonably and appropriately protect the confidentiality, integrity, and availability of the electronic protected health information that it creates, receives, maintains, or transmits in the execution of this Contract.

(e) The Contractor agrees to mitigate, to the extent practicable, any harmful effect that is known to the Contractor of a use or disclosure of Protected Health Information by the Contractor in violation of the requirements of this Contract.

(f) The Contractor agrees to report to the Government any security incident involving protected health information of which it becomes aware.

(g) The Contractor agrees to report to the Government any use or disclosure of the Protected Health Information not provided for by this Contract of which the Contractor becomes aware of.

(h) The Contractor agrees to ensure that any agent, including a subcontractor, to whom it provides Protected Health Information received from, or created or received by the Contractor on behalf of the Government agrees to the same restrictions and conditions that apply through this Contract to the Contractor with respect to such information.

(i) The Contractor agrees to ensure that any agent, including a subcontractor, to whom it provides electronic Protected Health Information, agrees to implement reasonable and appropriate safeguards to protect it.

(j) The Contractor agrees to provide access, at the request of the Government, and in the time and manner designated by the Government to Protected Health Information in a Designated Record Set, to the Government or, as directed by the Government, to an Individual in order to meet the requirements under 45 CFR 164.524.

(k) The Contractor agrees to make any amendment(s) to Protected Health Information in a Designated Record Set that the Government directs or agrees to pursuant to 45 CFR 164.526 at the request of the Government or an Individual, and in the time and manner designated by the Government.

(1) The Contractor agrees to make internal practices, books, and records relating to the use and disclosure of Protected Health Information received from, or created or received by the Contractor on behalf of, the Government, available to the Government, or at the request of the Government to the Secretary, in a time and manner designated by the 'Government or the Secretary, for purposes of the Secretary determining the Government's compliance with the Privacy Rule.

(m) The Contractor agrees to document such disclosures of Protected Health Information and information related to such disclosures as would be required for the Government to respond to a request by an Individual for an accounting of disclosures of Protected Health Information in accordance with 45 CFR 164.528.

(n) The Contractor agrees to provide to the Government or an Individual, in time and manner designated by the Government, information collected in accordance with this Clause of the Contract, to permit the Government to respond to a request by an Individual for an accounting of disclosures of Protected Health Information in accordance with 45 CFR 164.528.

General Use and Disclosure Provisions

Except as otherwise limited in this Agreement, the Contractor may use or disclose Protected Health Information on behalf of, or to provide services to, the Government for treatment, payment, or healthcare operations purposes, in accordance with the specific use and disclosure provisions below, if such use or disclosure of Protected Health Information would not violate the HIPAA Privacy Rule, DOD 6025.18-R, the HIPAA Security Rule, or DOD 8580.02-R if done by the Government.

Specific Use and Disclosure Provisions

(a) Except as otherwise limited in this Agreement, the Contractor may use Protected Health Information for the proper management and administration of the Contractor or to carry out the legal responsibilities of the Contractor.

(b) Except as otherwise limited in this Agreement, the Contractor may disclose Protected Health Information for the proper management and administration of the Contractor, provided that disclosures are required by law, or the Contractor obtains reasonable assurances from the person to whom the information is disclosed that it will remain confidential and used or further disclosed only as required by law or for the purpose for which it was disclosed to the person, and the person notifies the Contractor of any instances of which it is aware in which the confidentiality of the information has been breached.

(c) Except as otherwise limited in this Agreement, the Contractor may use Protected Health Information to provide Data Aggregation services to the Government as permitted by 45 CFR 164.504(e)(2)(i)(B).

(d) Contractor may use Protected Health Information to report violations of law to appropriate Federal and State authorities, consistent with 45 CFR 164.502(j)(1).

Obligations of the Government

Provisions for the Government to Inform the Contractor of Privacy Practices and Restrictions

(a) Upon request the Government shall provide the Contractor with the notice of privacy practices that the Government produces in accordance with 45 CFR 164.520, as well as any changes to such notice.

(b) The Government shall provide the Contractor with any changes in, or revocation of, permission by Individual to use or disclose Protected Health Information, if such changes affect the Contractor's permitted or required uses and disclosures.

(c) The Government shall notify the Contractor of any restriction to the use or disclosure of Protected Health Information that the Government has agreed to in accordance with 45 CFR 164.522.

Permissible Requests by the Government

The Government shall not request the Contractor to use or disclose Protected Health Information in any manner that would not be permissible under the HIPAA Privacy Rule, DOD 6025.18R, the HIPAA Security Rule, or DOD 8580.02-R, if done by the Government, except for providing Data Aggregation services to the Government and for management and administrative activities of the Contractor as otherwise permitted by this clause.

Termination

(a) Termination. A breach by the Contractor of this clause, may subject the Contractor to termination under any applicable default or termination provision of this Contract.

(b) Effect of Termination.

(1) If this contract has records management requirements, the records subject to the Clause should be handled in accordance with the records management requirements. If this contract does not have records management requirements, the records should be handled in accordance with paragraphs (2) and (3) below.

(2) If this contract does not have records management requirements, except as provided in paragraph (3) of this section, upon termination of this Contract, for any reason, the Contractor shall return or destroy all Protected Health Information received from the Government, or created or received by the Contractor on behalf of the Government. This provision shall apply to Protected Health Information that is in the possession of subcontractors or agents of the Contractor. The Contractor shall retain no copies of the Protected Health Information.

(3) If this contract does not have records management provisions and the Contractor determines that returning or destroying the Protected Health Information is infeasible, the Contractor shall provide to the Government notification of the conditions that make return or destruction infeasible. Upon mutual agreement of the Government and the Contractor that return or destruction of Protected Health Information is infeasible, the Contractor shall extend the protections of this Contract to such Protected Health Information and limit further uses and disclosures of such Protected Health Information to those purposes that make the return or destruction infeasible, for so long as the Contractor maintains such Protected Health Information.

Miscellaneous

(a) Regulatory References. A reference in this Clause to a section in DOD 6025.18-R, HIPAA Privacy Regulation or DOD 8580.02-R, HIPAA Security Regulation, or any CFR or AFI provision means the section as currently in effect or as amended, and for which compliance is required.

(b) Survival. The respective rights and obligations of Business Associate under the "Effect of Termination" provision of this Clause shall survive the termination of this Contract.

(c) Interpretation. Any ambiguity in this…