HSCEMD-17-R-00001_1449.pdf
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- Attached to
- Medical, Psychological, Fitness and Drug Testing
- Solicitation number
- HSCEMD-17-R-00001
- Issued by
-
Immigration and Customs Enforcement
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SEE ADDENDUMIS CHECKED
CODE 18a. PAYMENT WILL BE MADE BY
CODE
FACILITYCODE
17b. CHECK IF REMITTANCE IS DIFFERENT AND PUT SUCH ADDRESS IN OFFER
OFFEROR
ICE/IOSD
Dallas TX 75247
7701 N. Stemmons Freeway, Suite 300 Office of Acquisition Management Immigration and Customs Enforcement Investigations Ops Support Dallas
CODE 16. ADMINISTERED BYCODE
X
X
X
621498
SIZE STANDARD:
% FOR:SET ASIDE:UNRESTRICTED ORICE/IOSD
RFPIFB
10. THIS ACQUISITION ISCODE
RFQ
14. METHOD OF SOLICITATION
13b. RATING
NAICS:
SMALL BUSINESS
1700 CT214-905-5427Tasha Wang (No collect calls)
INFORMATION CALL:
FOR SOLICITATION 8. OFFER DUE DATE/LOCAL TIMEb. TELEPHONE NUMBER a. NAME
4. ORDER NUMBER3. AWARD/ 6. SOLICITATION
HSCEMD-17-R-00001
5. SOLICITATION NUMBER
SOLICITATION/CONTRACT/ORDER FOR COMMERCIAL ITEMS 1. REQUISITION NUMBER PAGE OF
1 45 OFFEROR TO COMPLETE BLOCKS 12, 17, 23, 24, & 30
Attn: Tasha Wang
TELEPHONE NO.
17a. CONTRACTOR/
15. DELIVER TO
Dallas TX 75247 7701 N. Stemmons Freeway, Suite 300 Office of Acquisition Management Immigration and Customs Enforcement
9. ISSUED BY
7.
2. CONTRACT NO.
EFFECTIVE DATE
$20.5
18b. SUBMIT INVOICES TO ADDRESS SHOWN IN BLOCK 18a UNLESS BLOCK BELOW
ISSUE DATE
DELIVERY FOR FOB DESTINA-
TION UNLESS BLOCK IS
MARKED
11.
SEE SCHEDULE
12. DISCOUNT TERMS
THIS CONTRACT IS A
RATED ORDER UNDER
DPAS (15 CFR 700)
13a.
SERVICE-DISABLED
VETERAN-OWNED
SMALL BUSINESS
HUBZONE SMALL
BUSINESS
8(A)
Investigations Ops Support Dallas
WOMEN-OWNED SMALL BUSINESS
(WOSB) ELIGIBLE UNDER THE WOMEN-OWNED
SMALL BUSINESS PROGRAM
EDWOSB
24.
AMOUNT
23.
UNIT PRICE
22.
UNIT
21.
QUANTITY
20.
SCHEDULE OF SUPPLIES/SERVICES
19.
ITEM NO.
The Department of Homeland Security (DHS), Immigration and Customs Enforcement (ICE), Office of Acquisitions (OAQ) is issuing this competitive request for proposals (RFP) to Solicit offers for the purpose of awarding a contract to provide medical, psychological, fitness and drug testing services for ICE employees throughout all 50 states, plus locations in Puerto Rico, the Virgin Islands, and the Mariana Islands to include Guam.
The awarded contract will be an Indefinite (Use Reverse and/or Attach Additional Sheets as Necessary)
HEREIN, IS ACCEPTED AS TO ITEMS:
X
XX
DATED
Richard Meier
. YOUR OFFER ON SOLICITATION (BLOCK 5),
INCLUDING ANY ADDITIONS OR CHANGES WHICH ARE SET FORTH
COPIES TO ISSUING OFFICE. CONTRACTOR AGREES TO FURNISH AND DELIVER
ARE
ARE
31c. DATE SIGNED
27b. CONTRACT/PURCHASE ORDER INCORPORATES BY REFERENCE FAR 52.212-4. FAR 52.212-5 IS ATTACHED. ADDENDA
31a. UNITED STATES OF AMERICA (SIGNATURE OF CONTRACTING OFFICER)
30c. DATE SIGNED 31b. NAME OF CONTRACTING OFFICER (Type or print)
ALL ITEMS SET FORTH OR OTHERWISE IDENTIFIED ABOVE AND ON ANY ADDITIONAL
SHEETS SUBJECT TO THE TERMS AND CONDITIONS SPECIFIED.
27a. SOLICITATION INCORPORATES BY REFERENCE FAR 52.212-1, 52.212-4. FAR 52.212-3 AND 52.212-5 ARE ATTACHED. ADDENDA
26. TOTAL AWARD AMOUNT (For Govt. Use Only)
OFFER
STANDARD FORM 1449 (REV. 2/2012)
Prescribed by GSA - FAR (48 CFR) 53.212
ARE NOT ATTACHED.
ARE NOT ATTACHED.
AUTHORIZED FOR LOCAL REPRODUCTION
PREVIOUS EDITION IS NOT USABLE
30b. NAME AND TITLE OF SIGNER (Type or print)
30a. SIGNATURE OF OFFEROR/CONTRACTOR
28. CONTRACTOR IS REQUIRED TO SIGN THIS DOCUMENT AND RETURN
25. ACCOUNTING AND APPROPRIATION DATA
29. AWARD OF CONTRACT:
REF.
32e. MAILING ADDRESS OF AUTHORIZED GOVERNMENT REPRESENTATIVE
32c. DATE 32b. SIGNATURE OF AUTHORIZED GOVERNMENT REPRESENTATIVE
ACCEPTED, AND CONFORMS TO THE CONTRACT, EXCEPT AS NOTED:
32a. QUANTITY IN COLUMN 21 HAS BEEN
RECEIVED INSPECTED
40. PAID BY39. S/R VOUCHER NUMBER38. S/R ACCOUNT NUMBER
37. CHECK NUMBER
FINALPARTIAL
36. PAYMENT
FINALPARTIAL
35. AMOUNT VERIFIED
CORRECT FOR
34. VOUCHER NUMBER33. SHIP NUMBER
COMPLETE
32g. E-MAIL OF AUTHORIZED GOVERNMENT REPRESENTATIVE
42d. TOTAL CONTAINERS42c. DATE REC'D (YY/MM/DD)
42b. RECEIVED AT (Location)
42a. RECEIVED BY (Print)
41c. DATE41b. SIGNATURE AND TITLE OF CERTIFYING OFFICER
41a. I CERTIFY THIS ACCOUNT IS CORRECT AND PROPER FOR PAYMENT
STANDARD FORM 1449 (REV. 2/2012) BACK
24.
AMOUNT
23.
UNIT PRICE
22.
UNIT
21.
QUANTITY
20.
SCHEDULE OF SUPPLIES/SERVICES
19.
ITEM NO.
Delivery / Indefinite Quantity Type of Contract, whereby Firm Fixed Price (FFP) and Time and
Material (T&M) task orders may be issued. The scope of the Performance Work Statement will support the U.S. Immigration and Customs
Enforcement Agency (ICE).
In accordance with FAR 16.504 Indefinite Quantity
Contracts-paragraph (b), the guaranteed minimum amount to be ordered under this contract is
$100,000.00.
Sensitive Award: HIPAA/PHI
Period of Performance: 08/01/2017 to 07/31/2022
0001 Ordering Period 1: Pre-Employment Medical Services
(Not Separately Priced)
Product/Service Code: Q999
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2017 to 07/31/2018
The quantities listed below are estimates only and are not purchased by this contract IAW FAR
52.216-22.
0001AA Ordering Period 1: Pre-Employment Medical 26000 EA
Examination
Product/Service Code: Q999
Continued ...
32f. TELEPHONE NUMBER OF AUTHORIZED GOVERNMENT REPRESENTATIVE
32d. PRINTED NAME AND TITLE OF AUTHORIZED GOVERNMENT REPRESENTATIVE
45 2 of
ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT
NAME OF OFFEROR OR CONTRACTOR
3 45
CONTINUATION SHEET
REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF
(A) (B) (C) (D) (E) (F)
HSCEMD-17-R-00001
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2017 to 07/31/2018
The quantities listed below are estimates only and are not purchased by this contract IAW FAR
52.216-22.
0001AB Ordering Period 1: Pre-Employment Physical 23000 EA
Fitness Test
Product/Service Code: Q999
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2017 to 07/31/2018
The quantities listed below are estimates only and are not purchased by this contract IAW FAR
52.216-22.
0001AC Ordering Period 1: Pre-Employment Drug Test 30000 EA
Product/Service Code: Q999
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2017 to 07/31/2018
The quantities listed below are estimates only and are not purchased by this contract IAW FAR
52.216-22.
0001AD Ordering Period 1: Expediting Fee upon request of 10 EA
Agency
Product/Service Code: Q999
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2017 to 07/31/2018
The quantities listed below are estimates only and are not purchased by this contract IAW FAR
52.216-22.
0001AE Ordering Period 1: Travel Funds (Not to Exceed)
The Government will fund this CLIN on a Not to
Exceed, as needed, basis. All Travel must be approved in writing by the COR and funded in advance by the Contracting Officer.
Continued ...
NSN 7540-01-152-8067 OPTIONAL FORM 336 (4-86)
Sponsored by GSA
FAR (48 CFR) 53.110
4 45
CONTINUATION SHEET
REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF
(A) (B) (C) (D) (E) (F)
HSCEMD-17-R-00001
Product/Service Code: Q999
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2017 to 07/31/2018
0002 Ordering Period 1: Fitness for Duty / Independent
Medical Examinations
(Not Separately Priced)
Product/Service Code: Q999
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2017 to 07/31/2018
The quantities listed below are estimates only and are not purchased by this contract IAW FAR
52.216-22.
0002AA Ordering Period 1: General Medical Independent 20 EA
Medical Examination with Report
Product/Service Code: Q999
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2017 to 07/31/2018
The quantities listed below are estimates only and are not purchased by this contract IAW FAR
52.216-22.
0002AB Ordering Period 1: Specialty Consultant
Independent Medical Examination with Report
(Not Separately Priced)
Product/Service Code: Q999
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2017 to 07/31/2018
The quantities listed below are estimates only and are not purchased by this contract IAW FAR
52.216-22.
0002AB1 Ordering Period 1: Specialty Consultant - 5 EA
Internal Medicine (IME) with Report
Product/Service Code: Q999
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2017 to 07/31/2018
Continued ...
NSN 7540-01-152-8067 OPTIONAL FORM 336 (4-86)
5 45
CONTINUATION SHEET
REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF
(A) (B) (C) (D) (E) (F)
HSCEMD-17-R-00001
The quantities listed below are estimates only and are not purchased by this contract IAW FAR
52.216-22.
0002AB2 Ordering Period 1: Specialty Consultant - 5 EA
Cardiology (IME) with Report
Product/Service Code: Q999
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2017 to 07/31/2018
The quantities listed below are estimates only and are not purchased by this contract IAW FAR
52.216-22.
0002AB3 Ordering Period 1: Specialty Consultant - 5 EA
Orthopedic (IME) with Report
Product/Service Code: Q999
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2017 to 07/31/2018
The quantities listed below are estimates only and are not purchased by this contract IAW FAR
52.216-22.
0002AB4 Ordering Period 1: Specialty Consultant - 5 EA
Psychiatric (IME) with Report
Product/Service Code: Q999
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2017 to 07/31/2018
The quantities listed below are estimates only and are not purchased by this contract IAW FAR
52.216-22.
0002AB5 Ordering Period 1: Specialty Consultant - 5 EA
Neurology (IME) with Report
Product/Service Code: Q999
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2017 to 07/31/2018
The quantities listed below are estimates only and are not purchased by this contract IAW FAR
52.216-22.
Continued ...
NSN 7540-01-152-8067 OPTIONAL FORM 336 (4-86)
6 45
CONTINUATION SHEET
REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF
(A) (B) (C) (D) (E) (F)
HSCEMD-17-R-00001
0002AC Ordering Period 1: Certified Independent Medical 6 EA
Evaluation with Report
Product/Service Code: Q999
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2017 to 07/31/2018
The quantities listed below are estimates only and are not purchased by this contract IAW FAR
52.216-22.
0002AD Ordering Period 1: Forensic Psychiatric 6 EA
Evaluation with Report
Product/Service Code: Q999
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2017 to 07/31/2018
The quantities listed below are estimates only and are not purchased by this contract IAW FAR
52.216-22.
0002AE Ordering Period 1: Independent Medical 5 EA
Examination - No Show
Product/Service Code: Q999
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2017 to 07/31/2018
The quantities listed below are estimates only and are not purchased by this contract IAW FAR
52.216-22.
0002AF Ordering Period 1: Secondary and Tertiary Reviews 450 HR
(Paper Only) BILLED AT AN HOURLY RATE
Product/Service Code: Q999
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2017 to 07/31/2018
The quantities listed below are estimates only and are not purchased by this contract IAW FAR
52.216-22.
0002AG Ordering Period 1: Internal Medicine (IME) 18 HR
Specialist, Additional Hours BILLED AT AN HOURLY
Continued ...
NSN 7540-01-152-8067 OPTIONAL FORM 336 (4-86)
7 45
CONTINUATION SHEET
REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF
(A) (B) (C) (D) (E) (F)
HSCEMD-17-R-00001
RATE
Product/Service Code: Q999
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2017 to 07/31/2018
The quantities listed below are estimates only and are not purchased by this contract IAW FAR
52.216-22.
0002AH Ordering Period 1: Cardiology (IME) Specialist, 18 HR
Additional Hours BILLED AT AN HOURLY RATE
Product/Service Code: Q999
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2017 to 07/31/2018
The quantities listed below are estimates only and are not purchased by this contract IAW FAR
52.216-22.
0002AI Ordering Period 1: Orthopedic (IME) Specialist, 18 HR
Additional Hours BILLED AT AN HOURLY RATE
Product/Service Code: Q999
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2017 to 07/31/2018
The quantities listed below are estimates only and are not purchased by this contract IAW FAR
52.216-22.
0002AJ Ordering Period 1: Psychiatric (IME) Specialist, 18 HR
Additional Hours BILLED AT AN HOURLY RATE
Product/Service Code: Q999
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2017 to 07/31/2018
The quantities listed below are estimates only and are not purchased by this contract IAW FAR
52.216-22.
0002AK Ordering Period 1: Internal Medicine (IME) 18 HR
Specialist, Additional Hours BILLED AT AN HOURLY
RATE
Product/Service Code: Q999
Continued ...
NSN 7540-01-152-8067 OPTIONAL FORM 336 (4-86)
8 45
CONTINUATION SHEET
REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF
(A) (B) (C) (D) (E) (F)
HSCEMD-17-R-00001
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2017 to 07/31/2018
The quantities listed below are estimates only and are not purchased by this contract IAW FAR
52.216-22.
0002AL Ordering Period 1: Neurology (IME) Specialist, 18 HR
Additional Hours BILLED AT AN HOURLY RATE
Product/Service Code: Q999
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2017 to 07/31/2018
The quantities listed below are estimates only and are not purchased by this contract IAW FAR
52.216-22.
0002AM Ordering Period 1: Medical Tests (prior approval required)
(Not Separately Priced)
Product/Service Code: Q999
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2017 to 07/31/2018
0003 Ordering Period 1: Drug Free Federal Workplace
(Not Separately Priced)
Product/Service Code: Q999
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2017 to 07/31/2018
The quantities listed below are estimates only and are not purchased by this contract IAW FAR
52.216-22.
0003AA Ordering Period 1: Random Drug Test Urinalysis 2687 EA
Collection
Product/Service Code: Q999
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2017 to 07/31/2018
The quantities listed below are estimates only and are not purchased by this contract IAW FAR
Continued ...
NSN 7540-01-152-8067 OPTIONAL FORM 336 (4-86)
9 45
CONTINUATION SHEET
REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF
(A) (B) (C) (D) (E) (F)
HSCEMD-17-R-00001
52.216-22.
0003AB Ordering Period 1: Post-Accident Drug Test 30 EA
Urinalysis Collection
Product/Service Code: Q999
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2017 to 07/31/2018
The quantities listed below are estimates only and are not purchased by this contract IAW FAR
52.216-22.
0003AC Ordering Period 1: Reasonable Suspicion Drug Test 30 EA
Urinalysis Collection
Product/Service Code: Q999
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2017 to 07/31/2018
The quantities listed below are estimates only and are not purchased by this contract IAW FAR
52.216-22.
0003AD Ordering Period 1: Statistician for Random Drug 12 EA
Test
Product/Service Code: Q999
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2017 to 07/31/2018
The quantities listed below are estimates only and are not purchased by this contract IAW FAR
52.216-22.
0003AE Ordering Period 1: Litigation Package (Laboratory 10 EA
Documentation for Positive Drug Tests Reports)
Product/Service Code: Q999
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2017 to 07/31/2018
0004 Ordering Period 1: One Stop Mobile Events
(Not Separately Priced)
Product/Service Code: Q999
Product/Service Description: MEDICAL- OTHER
Continued ...
NSN 7540-01-152-8067 OPTIONAL FORM 336 (4-86)
10 45
CONTINUATION SHEET
REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF
(A) (B) (C) (D) (E) (F)
HSCEMD-17-R-00001
Period of Performance: 08/01/2017 to 07/31/2018
The quantities listed below are estimates only and are not purchased by this contract IAW FAR
52.216-22.
0004AA Ordering Period 1: One Stop Mobile Event with 2 EA
Fitness Testing (3 day event)
Product/Service Code: Q999
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2017 to 07/31/2018
The quantities listed below are estimates only and are not purchased by this contract IAW FAR
52.216-22.
0004AC Ordering Period 1: One Stop Mobile Event with 2 EA
Fitness Testing (5 day event)
Product/Service Code: Q999
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2017 to 07/31/2018
The quantities listed below are estimates only and are not purchased by this contract IAW FAR
52.216-22.
0004AD Ordering Period 1: One Stop Mobile Event minus 2 EA
Fitness Testing (3 day event)
Product/Service Code: Q999
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2017 to 07/31/2018
The quantities listed below are estimates only and are not purchased by this contract IAW FAR
52.216-22.
0004AE Ordering Period 1: One Stop Mobile Event minus 2 EA
Fitness Testing (4 day event)
Product/Service Code: Q999
Continued ...
NSN 7540-01-152-8067 OPTIONAL FORM 336 (4-86)
11 45
CONTINUATION SHEET
REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF
(A) (B) (C) (D) (E) (F)
HSCEMD-17-R-00001
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2017 to 07/31/2018
The quantities listed below are estimates only and are not purchased by this contract IAW FAR
52.216-22.
0004AF Ordering Period 1: One Stop Mobile Event minus 2 EA
Fitness Testing (5 day event)
Product/Service Code: Q999
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2017 to 07/31/2018
1001 Ordering Period 2: Pre-Employment Medical Services
(Not Separately Priced)
Product/Service Code: Q999
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2018 to 07/31/2019
The quantities listed below are estimates only and are not purchased by this contract IAW FAR
52.216-22.
1001AA Ordering Period 2: Pre-Employment Medical 26000 EA
Examination
Product/Service Code: Q999
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2018 to 07/31/2019
The quantities listed below are estimates only and are not purchased by this contract IAW FAR
52.216-22.
1001AB Ordering Period 2: Pre-Employment Physical 23000 EA
Fitness Test
Product/Service Code: Q999
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2018 to 07/31/2019
The quantities listed below are estimates only and are not purchased by this contract IAW FAR
Continued ...
NSN 7540-01-152-8067 OPTIONAL FORM 336 (4-86)
12 45
CONTINUATION SHEET
REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF
(A) (B) (C) (D) (E) (F)
HSCEMD-17-R-00001
52.216-22.
1001AC Ordering Period 2: Pre-Employment Drug Test 30000 EA
Product/Service Code: Q999
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2018 to 07/31/2019
The quantities listed below are estimates only and are not purchased by this contract IAW FAR
52.216-22.
1001AD Ordering Period 2: Expediting Fee upon request of 10 EA
Agency
Product/Service Code: Q999
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2018 to 07/31/2019
The quantities listed below are estimates only and are not purchased by this contract IAW FAR
52.216-22.
1001AE Ordering Period 2: Travel Funds (Not to Exceed)
The Government will fund this CLIN on a Not to
Exceed, as needed, basis. All Travel must be approved in writing by the COR and funded in advance by the Contracting Officer.
Product/Service Code: Q999
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2018 to 07/31/2019
1002 Ordering Period 2: Fitness for Duty / Independent
Medical Examinations
(Not Separately Priced)
Product/Service Code: Q999
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2018 to 07/31/2019
The quantities listed below are estimates only and are not purchased by this contract IAW FAR
52.216-22.
1002AA Ordering Period 2: General Medical Independent 20 EA
Continued ...
NSN 7540-01-152-8067 OPTIONAL FORM 336 (4-86)
13 45
CONTINUATION SHEET
REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF
(A) (B) (C) (D) (E) (F)
HSCEMD-17-R-00001
Medical Examination with Report
Product/Service Code: Q999
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2018 to 07/31/2019
The quantities listed below are estimates only and are not purchased by this contract IAW FAR
52.216-22.
1002AB Ordering Period 2: Specialty Consultant
Independent Medical Examination with Report
(Not Separately Priced)
Product/Service Code: Q999
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2018 to 07/31/2019
The quantities listed below are estimates only and are not purchased by this contract IAW FAR
52.216-22.
1002AB1 Ordering Period 2: Specialty Consultant - 5 EA
Internal Medicine (IME) with Report
Product/Service Code: Q999
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2018 to 07/31/2019
The quantities listed below are estimates only and are not purchased by this contract IAW FAR
52.216-22.
1002AB2 Ordering Period 2: Specialty Consultant - 5 EA
Cardiology (IME) with Report
Product/Service Code: Q999
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2018 to 07/31/2019
The quantities listed below are estimates only and are not purchased by this contract IAW FAR
52.216-22.
1002AB3 Ordering Period 2: Specialty Consultant - 5 EA
Orthopedic (IME) with Report
Product/Service Code: Q999
Continued ...
NSN 7540-01-152-8067 OPTIONAL FORM 336 (4-86)
14 45
CONTINUATION SHEET
REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF
(A) (B) (C) (D) (E) (F)
HSCEMD-17-R-00001
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2018 to 07/31/2019
The quantities listed below are estimates only and are not purchased by this contract IAW FAR
52.216-22.
1002AB4 Ordering Period 2: Specialty Consultant - 5 EA
Psychiatric (IME) with Report
Product/Service Code: Q999
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2018 to 07/31/2019
The quantities listed below are estimates only and are not purchased by this contract IAW FAR
52.216-22.
1002AB5 Ordering Period 2: Specialty Consultant - 5 EA
Neurology (IME) with Report
Product/Service Code: Q999
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2018 to 07/31/2019
The quantities listed below are estimates only and are not purchased by this contract IAW FAR
52.216-22.
1002AC Ordering Period 2: Certified Independent Medical 6 EA
Evaluation with Report
Product/Service Code: Q999
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2018 to 07/31/2019
The quantities listed below are estimates only and are not purchased by this contract IAW FAR
52.216-22.
1002AD Ordering Period 2: Forensic Psychiatric 6 EA
Evaluation with Report
Product/Service Code: Q999
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2018 to 07/31/2019
Continued ...
NSN 7540-01-152-8067 OPTIONAL FORM 336 (4-86)
15 45
CONTINUATION SHEET
REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF
(A) (B) (C) (D) (E) (F)
HSCEMD-17-R-00001
The quantities listed below are estimates only and are not purchased by this contract IAW FAR
52.216-22.
1002AE Ordering Period 2: Independent Medical 5 EA
Examination - No Show
Product/Service Code: Q999
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2018 to 07/31/2019
The quantities listed below are estimates only and are not purchased by this contract IAW FAR
52.216-22.
1002AF Ordering Period 2: Secondary and Tertiary Reviews 450 HR
(Paper Only) BILLED AT AN HOURLY RATE
Product/Service Code: Q999
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2018 to 07/31/2019
The quantities listed below are estimates only and are not purchased by this contract IAW FAR
52.216-22.
1002AG Ordering Period 2: Internal Medicine (IME) 18 HR
Specialist, Additional Hours BILLED AT AN HOURLY
RATE
Product/Service Code: Q999
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2018 to 07/31/2019
The quantities listed below are estimates only and are not purchased by this contract IAW FAR
52.216-22.
1002AH Ordering Period 2: Cardiology (IME) Specialist, 18 HR
Additional Hours BILLED AT AN HOURLY RATE
Product/Service Code: Q999
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2018 to 07/31/2019
The quantities listed below are estimates only
Continued ...
NSN 7540-01-152-8067 OPTIONAL FORM 336 (4-86)
16 45
CONTINUATION SHEET
REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF
(A) (B) (C) (D) (E) (F)
HSCEMD-17-R-00001
and are not purchased by this contract IAW FAR
52.216-22.
1002AI Ordering Period 2: Orthopedic (IME) Specialist, 18 HR
Additional Hours BILLED AT AN HOURLY RATE
Product/Service Code: Q999
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2018 to 07/31/2019
The quantities listed below are estimates only and are not purchased by this contract IAW FAR
52.216-22.
1002AJ Ordering Period 2: Psychiatric (IME) Specialist, 18 HR
Additional Hours BILLED AT AN HOURLY RATE
Product/Service Code: Q999
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2018 to 07/31/2019
The quantities listed below are estimates only and are not purchased by this contract IAW FAR
52.216-22.
1002AK Ordering Period 2: Internal Medicine (IME) 18 HR
Specialist, Additional Hours BILLED AT AN HOURLY
RATE
Product/Service Code: Q999
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2018 to 07/31/2019
The quantities listed below are estimates only and are not purchased by this contract IAW FAR
52.216-22.
1002AL Ordering Period 2: Neurology (IME) Specialist, 18 HR
Additional Hours BILLED AT AN HOURLY RATE
Product/Service Code: Q999
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2018 to 07/31/2019
1003 Ordering Period 2: Drug Free Federal Workplace
(Not Separately Priced)
Product/Service Code: Q999
Continued ...
NSN 7540-01-152-8067 OPTIONAL FORM 336 (4-86)
17 45
CONTINUATION SHEET
REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF
(A) (B) (C) (D) (E) (F)
HSCEMD-17-R-00001
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2018 to 07/31/2019
The quantities listed below are estimates only and are not purchased by this contract IAW FAR
52.216-22.
1003AA Ordering Period 2: Random Drug Test Urinalysis 2687 EA
Collection
Product/Service Code: Q999
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2018 to 07/31/2019
The quantities listed below are estimates only and are not purchased by this contract IAW FAR
52.216-22.
1003AB Ordering Period 2: Post-Accident Drug Test 30 EA
Urinalysis Collection
Product/Service Code: Q999
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2018 to 07/31/2019
The quantities listed below are estimates only and are not purchased by this contract IAW FAR
52.216-22.
1003AC Ordering Period 2: Reasonable Suspicion Drug Test 30 EA
Urinalysis Collection
Product/Service Code: Q999
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2018 to 07/31/2019
The quantities listed below are estimates only and are not purchased by this contract IAW FAR
52.216-22.
1003AD Ordering Period 2: Statistician for Random Drug 12 EA
Test
Product/Service Code: Q999
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2018 to 07/31/2019
Continued ...
NSN 7540-01-152-8067 OPTIONAL FORM 336 (4-86)
18 45
CONTINUATION SHEET
REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF
(A) (B) (C) (D) (E) (F)
HSCEMD-17-R-00001
The quantities listed below are estimates only and are not purchased by this contract IAW FAR
52.216-22.
1003AE Ordering Period 2: Litigation Package (Laboratory 5 EA
Documentation for Positive Drug Tests Reports)
Product/Service Code: Q999
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2018 to 07/31/2019
1004 Ordering Period 2: One Stop Mobile Events
(Not Separately Priced)
Product/Service Code: Q999
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2018 to 07/31/2019
The quantities listed below are estimates only and are not purchased by this contract IAW FAR
52.216-22.
1004AA Ordering Period 2: One Stop Mobile Event with 2 EA
Fitness Testing (3 day event)
Product/Service Code: Q999
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2018 to 07/31/2019
The quantities listed below are estimates only and are not purchased by this contract IAW FAR
52.216-22.
1004AB Ordering Period 2: One Stop Mobile Event with 2 EA
Fitness Testing (4 day event)
Product/Service Code: Q999
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2018 to 07/31/2019
The quantities listed below are estimates only and are not purchased by this contract IAW FAR
52.216-22.
Continued ...
NSN 7540-01-152-8067 OPTIONAL FORM 336 (4-86)
19 45
CONTINUATION SHEET
REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF
(A) (B) (C) (D) (E) (F)
HSCEMD-17-R-00001
1004AC Ordering Period 2: One Stop Mobile Event with 2 EA
Fitness Testing (5 day event)
Product/Service Code: Q999
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2018 to 07/31/2019
The quantities listed below are estimates only and are not purchased by this contract IAW FAR
52.216-22.
1004AD Ordering Period 2: One Stop Mobile Event minus 2 EA
Fitness Testing (3 day event)
Product/Service Code: Q999
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2018 to 07/31/2019
The quantities listed below are estimates only and are not purchased by this contract IAW FAR
52.216-22.
1004AE Ordering Period 2: One Stop Mobile Event minus 2 EA
Fitness Testing (4 day event)
Product/Service Code: Q999
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2018 to 07/31/2019
The quantities listed below are estimates only and are not purchased by this contract IAW FAR
52.216-22.
1004AF Ordering Period 2: One Stop Mobile Event minus 2 EA
Fitness Testing (5 day event)
Product/Service Code: Q999
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2018 to 07/31/2019
2001 Ordering Period 3: Pre-Employment Medical Services
(Not Separately Priced)
Product/Service Code: Q999
Continued ...
NSN 7540-01-152-8067 OPTIONAL FORM 336 (4-86)
20 45
CONTINUATION SHEET
REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF
(A) (B) (C) (D) (E) (F)
HSCEMD-17-R-00001
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2019 to 07/31/2020
The quantities listed below are estimates only and are not purchased by this contract IAW FAR
52.216-22.
2001AA Ordering Period 3: Pre-Employment Medical 26000 EA
Examination
Product/Service Code: Q999
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2019 to 07/31/2020
The quantities listed below are estimates only and are not purchased by this contract IAW FAR
52.216-22.
2001AB Ordering Period 3: Pre-Employment Physical 23000 EA
Fitness Test
Product/Service Code: Q999
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2019 to 07/31/2020
The quantities listed below are estimates only and are not purchased by this contract IAW FAR
52.216-22.
2001AC Ordering Period 3: Pre-Employment Drug Test 30000 EA
Product/Service Code: Q999
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2019 to 07/31/2020
The quantities listed below are estimates only and are not purchased by this contract IAW FAR
52.216-22.
2001AD Ordering Period 3: Expediting Fee upon request of 10 EA
Agency
Product/Service Code: Q999
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2019 to 07/31/2020
Continued ...
NSN 7540-01-152-8067 OPTIONAL FORM 336 (4-86)
21 45
CONTINUATION SHEET
REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF
(A) (B) (C) (D) (E) (F)
HSCEMD-17-R-00001
The quantities listed below are estimates only and are not purchased by this contract IAW FAR
52.216-22.
2001AE Ordering Period 3: Travel Funds (Not to Exceed)
The Government will fund this CLIN on a Not to
Exceed, as needed, basis. All Travel must be approved in writing by the COR and funded in advance by the Contracting Officer.
Product/Service Code: Q999
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2019 to 07/31/2020
2002 Ordering Period 3: Fitness for Duty / Independent
Medical Examinations
(Not Separately Priced)
Product/Service Code: Q999
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2019 to 07/31/2020
The quantities listed below are estimates only and are not purchased by this contract IAW FAR
52.216-22.
2002AA Ordering Period 3: General Medical Independent 20 EA
Medical Examination with Report
Product/Service Code: Q999
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2019 to 07/31/2020
The quantities listed below are estimates only and are not purchased by this contract IAW FAR
52.216-22.
2002AB Ordering Period 3: Specialty Consultant
Independent Medical Examination with Report
(Not Separately Priced)
Product/Service Code: Q999
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2019 to 07/31/2020
The quantities listed below are estimates only
Continued ...
NSN 7540-01-152-8067 OPTIONAL FORM 336 (4-86)
22 45
CONTINUATION SHEET
REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF
(A) (B) (C) (D) (E) (F)
HSCEMD-17-R-00001
and are not purchased by this contract IAW FAR
52.216-22.
2002AB1 Ordering Period 3: Specialty Consultant - 5 EA
Internal Medicine (IME) with Report
Product/Service Code: Q999
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2019 to 07/31/2020
The quantities listed below are estimates only and are not purchased by this contract IAW FAR
52.216-22.
2002AB2 Ordering Period 3: Specialty Consultant - 5 EA
Cardiology (IME) with Report
Product/Service Code: Q999
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2019 to 07/31/2020
The quantities listed below are estimates only and are not purchased by this contract IAW FAR
52.216-22.
2002AB3 Ordering Period 3: Specialty Consultant - 5 EA
Orthopedic (IME) with Report
Product/Service Code: Q999
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2019 to 07/31/2020
The quantities listed below are estimates only and are not purchased by this contract IAW FAR
52.216-22.
2002AB4 Ordering Period 3: Specialty Consultant - 5 EA
Psychiatric (IME) with Report
Product/Service Code: Q999
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2019 to 07/31/2020
The quantities listed below are estimates only and are not purchased by this contract IAW FAR
52.216-22.
Continued ...
NSN 7540-01-152-8067 OPTIONAL FORM 336 (4-86)
23 45
CONTINUATION SHEET
REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF
(A) (B) (C) (D) (E) (F)
HSCEMD-17-R-00001
2002AB5 Ordering Period 3: Specialty Consultant - 5 EA
Neurology (IME) with Report
Product/Service Code: Q999
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2019 to 07/31/2020
The quantities listed below are estimates only and are not purchased by this contract IAW FAR
52.216-22.
2002AC Ordering Period 3: Certified Independent Medical 6 EA
Evaluation with Report
Product/Service Code: Q999
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2019 to 07/31/2020
The quantities listed below are estimates only and are not purchased by this contract IAW FAR
52.216-22.
2002AD Ordering Period 3: Forensic Psychiatric 6 EA
Evaluation with Report
Product/Service Code: Q999
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2019 to 07/31/2020
The quantities listed below are estimates only and are not purchased by this contract IAW FAR
52.216-22.
2002AE Ordering Period 3: Independent Medical 5 EA
Examination - No Show
Product/Service Code: Q999
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2019 to 07/31/2020
The quantities listed below are estimates only and are not purchased by this contract IAW FAR
52.216-22.
2002AF Ordering Period 3: Secondary and Tertiary Reviews 450 HR
(Paper Only) BILLED AT AN HOURLY RATE
Product/Service Code: Q999
Continued ...
NSN 7540-01-152-8067 OPTIONAL FORM 336 (4-86)
24 45
CONTINUATION SHEET
REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF
(A) (B) (C) (D) (E) (F)
HSCEMD-17-R-00001
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2019 to 07/31/2020
The quantities listed below are estimates only and are not purchased by this contract IAW FAR
52.216-22.
2002AG Ordering Period 3: Internal Medicine (IME) 18 HR
Specialist, Additional Hours BILLED AT AN HOURLY
RATE
Product/Service Code: Q999
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2019 to 07/31/2020
The quantities listed below are estimates only and are not purchased by this contract IAW FAR
52.216-22.
2002AH Ordering Period 3: Cardiology (IME) Specialist, 18 HR
Additional Hours BILLED AT AN HOURLY RATE
Product/Service Code: Q999
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2019 to 07/31/2020
The quantities listed below are estimates only and are not purchased by this contract IAW FAR
52.216-22.
2002AI Ordering Period 3: Orthopedic (IME) Specialist, 18 HR
Additional Hours BILLED AT AN HOURLY RATE
Product/Service Code: Q999
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2019 to 07/31/2020
The quantities listed below are estimates only and are not purchased by this contract IAW FAR
52.216-22.
2002AJ Ordering Period 3: Psychiatric (IME) Specialist, 18 HR
Additional Hours BILLED AT AN HOURLY RATE
Product/Service Code: Q999
Product/Service Description: MEDICAL- OTHER
Continued ...
NSN 7540-01-152-8067 OPTIONAL FORM 336 (4-86)
25 45
CONTINUATION SHEET
REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF
(A) (B) (C) (D) (E) (F)
HSCEMD-17-R-00001
Period of Performance: 08/01/2019 to 07/31/2020
The quantities listed below are estimates only and are not purchased by this contract IAW FAR
52.216-22.
2002AK Ordering Period 3: Internal Medicine (IME) 18 HR
Specialist, Additional Hours BILLED AT AN HOURLY
RATE
Product/Service Code: Q999
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2019 to 07/31/2020
The quantities listed below are estimates only and are not purchased by this contract IAW FAR
52.216-22.
2002AL Ordering Period 3: Neurology (IME) Specialist, 18 HR
Additional Hours BILLED AT AN HOURLY RATE
Product/Service Code: Q999
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2019 to 07/31/2020
2003 Ordering Period 3: Drug Free Federal Workplace
(Not Separately Priced)
Product/Service Code: Q999
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2019 to 07/31/2020
The quantities listed below are estimates only and are not purchased by this contract IAW FAR
52.216-22.
2003AA Ordering Period 3: Random Drug Test Urinalysis 2687 EA
Collection
Product/Service Code: Q999
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2019 to 07/31/2020
The quantities listed below are estimates only and are not purchased by this contract IAW FAR
52.216-22.
Continued ...
NSN 7540-01-152-8067 OPTIONAL FORM 336 (4-86)
26 45
CONTINUATION SHEET
REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF
(A) (B) (C) (D) (E) (F)
HSCEMD-17-R-00001
2003AB Ordering Period 3: Post-Accident Drug Test 30 EA
Urinalysis Collection
Product/Service Code: Q999
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2019 to 07/31/2020
The quantities listed below are estimates only and are not purchased by this contract IAW FAR
52.216-22.
2003AC Ordering Period 3: Reasonable Suspicion Drug Test 15 EA
Urinalysis Collection
Product/Service Code: Q999
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2019 to 07/31/2020
The quantities listed below are estimates only and are not purchased by this contract IAW FAR
52.216-22.
2003AD Ordering Period 3: Statistician for Random Drug 12 EA
Test
Product/Service Code: Q999
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2019 to 07/31/2020
The quantities listed below are estimates only and are not purchased by this contract IAW FAR
52.216-22.
2003AE Ordering Period 3: Litigation Package (Laboratory 10 EA
Documentation for Positive Drug Tests Reports)
Product/Service Code: Q999
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2019 to 07/31/2020
2004 Ordering Period 3: One Stop Mobile Events
(Not Separately Priced)
Product/Service Code: Q999
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2019 to 07/31/2020
Continued ...
NSN 7540-01-152-8067 OPTIONAL FORM 336 (4-86)
27 45
CONTINUATION SHEET
REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF
(A) (B) (C) (D) (E) (F)
HSCEMD-17-R-00001
The quantities listed below are estimates only and are not purchased by this contract IAW FAR
52.216-22.
2004AA Ordering Period 3: One Stop Mobile Event with 2 EA
Fitness Testing (3 day event)
Product/Service Code: Q999
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2019 to 07/31/2020
The quantities listed below are estimates only and are not purchased by this contract IAW FAR
52.216-22.
2004AB Ordering Period 3: One Stop Mobile Event with 2 EA
Fitness Testing (4 day event)
Product/Service Code: Q999
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2019 to 07/31/2020
The quantities listed below are estimates only and are not purchased by this contract IAW FAR
52.216-22.
2004AC Ordering Period 3: One Stop Mobile Event with 2 EA
Fitness Testing (5 day event)
Product/Service Code: Q999
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2019 to 07/31/2020
The quantities listed below are estimates only and are not purchased by this contract IAW FAR
52.216-22.
2004AD Ordering Period 3: One Stop Mobile Event minus 2 EA
Fitness Testing (3 day event)
Product/Service Code: Q999
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2019 to 07/31/2020
Continued ...
NSN 7540-01-152-8067 OPTIONAL FORM 336 (4-86)
28 45
CONTINUATION SHEET
REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF
(A) (B) (C) (D) (E) (F)
HSCEMD-17-R-00001
The quantities listed below are estimates only and are not purchased by this contract IAW FAR
52.216-22.
2004AE Ordering Period 3: One Stop Mobile Event minus 2 EA
Fitness Testing (4 day event)
Product/Service Code: Q999
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2019 to 07/31/2020
The quantities listed below are estimates only and are not purchased by this contract IAW FAR
52.216-22.
2004AF Ordering Period 3: One Stop Mobile Event minus 2 EA
Fitness Testing (5 day event)
Product/Service Code: Q999
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2019 to 07/31/2020
3001 Ordering Period 4: Pre-Employment Medical Services
(Not Separately Priced)
Product/Service Code: Q999
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2020 to 07/31/2021
The quantities listed below are estimates only and are not purchased by this contract IAW FAR
52.216-22.
3001AA Ordering Period 4: Pre-Employment Medical 26000 EA
Examination
Product/Service Code: Q999
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2020 to 07/31/2021
The quantities listed below are estimates only and are not purchased by this contract IAW FAR
52.216-22.
Continued ...
NSN 7540-01-152-8067 OPTIONAL FORM 336 (4-86)
29 45
CONTINUATION SHEET
REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF
(A) (B) (C) (D) (E) (F)
HSCEMD-17-R-00001
3001AB Ordering Period 4: Pre-Employment Physical 23000 EA
Fitness Test
Product/Service Code: Q999
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2020 to 07/31/2021
The quantities listed below are estimates only and are not purchased by this contract IAW FAR
52.216-22.
3001AC Ordering Period 4: Pre-Employment Drug Test 30000 EA
Product/Service Code: Q999
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2020 to 07/31/2021
The quantities listed below are estimates only and are not purchased by this contract IAW FAR
52.216-22.
3001AD Ordering Period 4: Expediting Fee upon request of 10 EA
Agency
Product/Service Code: Q999
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2020 to 07/31/2021
The quantities listed below are estimates only and are not purchased by this contract IAW FAR
52.216-22.
3001AE Ordering Period 4: Travel Funds (Not to Exceed)
The Government will fund this CLIN on a Not to
Exceed, as needed, basis. All Travel must be approved in writing by the COR and funded in advance by the Contracting Officer.
Product/Service Code: Q999
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2020 to 07/31/2021
3002 Ordering Period 4: Fitness for Duty / Independent
Medical Examinations
(Not Separately Priced)
Product/Service Code: Q999
Continued ...
NSN 7540-01-152-8067 OPTIONAL FORM 336 (4-86)
30 45
CONTINUATION SHEET
REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF
(A) (B) (C) (D) (E) (F)
HSCEMD-17-R-00001
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2020 to 07/31/2021
The quantities listed below are estimates only and are not purchased by this contract IAW FAR
52.216-22.
3002AA Ordering Period 4: General Medical Independent 20 EA
Medical Examination with Report
Product/Service Code: Q999
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2020 to 07/31/2021
The quantities listed below are estimates only and are not purchased by this contract IAW FAR
52.216-22.
3002AB Ordering Period 4: Specialty Consultant
Independent Medical Examination with Report
(Not Separately Priced)
Product/Service Code: Q999
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2020 to 07/31/2021
The quantities listed below are estimates only and are not purchased by this contract IAW FAR
52.216-22.
3002AB1 Ordering Period 4: Specialty Consultant - 5 EA
Internal Medicine (IME) with Report
Product/Service Code: Q999
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2020 to 07/31/2021
The quantities listed below are estimates only and are not purchased by this contract IAW FAR
52.216-22.
3002AB2 Ordering Period 4: Specialty Consultant - 5 EA
Cardiology (IME) with Report
Product/Service Code: Q999
Product/Service Description: MEDICAL- OTHER
Continued ...
NSN 7540-01-152-8067 OPTIONAL FORM 336 (4-86)
31 45
CONTINUATION SHEET
REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF
(A) (B) (C) (D) (E) (F)
HSCEMD-17-R-00001
Period of Performance: 08/01/2020 to 07/31/2021
The quantities listed below are estimates only and are not purchased by this contract IAW FAR
52.216-22.
3002AB3 Ordering Period 4: Specialty Consultant - 5 EA
Orthopedic (IME) with Report
Product/Service Code: Q999
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2020 to 07/31/2021
The quantities listed below are estimates only and are not purchased by this contract IAW FAR
52.216-22.
3002AB4 Ordering Period 4: Specialty Consultant - 5 EA
Psychiatric (IME) with Report
Product/Service Code: Q999
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2020 to 07/31/2021
The quantities listed below are estimates only and are not purchased by this contract IAW FAR
52.216-22.
3002AB5 Ordering Period 4: Specialty Consultant - 5 EA
Neurology (IME) with Report
Product/Service Code: Q999
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2020 to 07/31/2021
The quantities listed below are estimates only and are not purchased by this contract IAW FAR
52.216-22.
3002AC Ordering Period 4: Certified Independent Medical 6 EA
Evaluation with Report
Product/Service Code: Q999
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2020 to 07/31/2021
The quantities listed below are estimates only
Continued ...
NSN 7540-01-152-8067 OPTIONAL FORM 336 (4-86)
32 45
CONTINUATION SHEET
REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF
(A) (B) (C) (D) (E) (F)
HSCEMD-17-R-00001
and are not purchased by this contract IAW FAR
52.216-22.
3002AD Ordering Period 4: Forensic Psychiatric 6 EA
Evaluation with Report
Product/Service Code: Q999
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2020 to 07/31/2021
The quantities listed below are estimates only and are not purchased by this contract IAW FAR
52.216-22.
3002AE Ordering Period 4: Independent Medical 5 EA
Examination - No Show
Product/Service Code: Q999
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2020 to 07/31/2021
The quantities listed below are estimates only and are not purchased by this contract IAW FAR
52.216-22.
3002AF Ordering Period 4: Secondary and Tertiary Reviews 450 HR
(Paper Only) BILLED AT AN HOURLY RATE
Product/Service Code: Q999
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2020 to 07/31/2021
The quantities listed below are estimates only and are not purchased by this contract IAW FAR
52.216-22.
3002AG Ordering Period 4: Internal Medicine (IME) 18 HR
Specialist, Additional Hours BILLED AT AN HOURLY
RATE
Product/Service Code: Q999
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2020 to 07/31/2021
The quantities listed below are estimates only and are not purchased by this contract IAW FAR
52.216-22.
Continued ...
NSN 7540-01-152-8067 OPTIONAL FORM 336 (4-86)
33 45
CONTINUATION SHEET
REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF
(A) (B) (C) (D) (E) (F)
HSCEMD-17-R-00001
3002AH Ordering Period 4: Cardiology (IME) Specialist, 18 HR
Additional Hours BILLED AT AN HOURLY RATE
Product/Service Code: Q999
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2020 to 07/31/2021
The quantities listed below are estimates only and are not purchased by this contract IAW FAR
52.216-22.
3002AI Ordering Period 4: Orthopedic (IME) Specialist, 18 HR
Additional Hours BILLED AT AN HOURLY RATE
Product/Service Code: Q999
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2020 to 07/31/2021
The quantities listed below are estimates only and are not purchased by this contract IAW FAR
52.216-22.
3002AJ Ordering Period 4: Psychiatric (IME) Specialist, 18 HR
Additional Hours BILLED AT AN HOURLY RATE
Product/Service Code: Q999
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2020 to 07/31/2021
The quantities listed below are estimates only and are not purchased by this contract IAW FAR
52.216-22.
3002AK Ordering Period 4: Internal Medicine (IME) 18 HR
Specialist, Additional Hours BILLED AT AN HOURLY
RATE
Product/Service Code: Q999
Product/Service Description: MEDICAL- OTHER
Period of Performance: 08/01/2020 to 07/31/2021
The quantities listed below are estimates only and are not purchased by this contract IAW FAR
52.216-22.
3002AL Ordering Period 4:…
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